iiMinwii 



CLINICAL LECTURES, 



ROBERT jf GRAVES, M.D., M.R.I.A., 

PROFESSOR OF THE INSTITUTES OF MEDICINE IN THE SCHOOL OF PHYSIC, TRINITY 
COLLEGE, DUBLIN, ETC., ETC., ETC. 



SECOND AMERICAN EDITION, 



NOTES AND 1 SERIES OF LECTURES, 



W. W. GERHARD, M.D., 

LECTURER ON CLINICAL MEDICINE TO THE UNIVERSITY OF PENNSYLVANIA, 

PHYSICIAN TO THE PHILADELPHIA HOSPITAL, BLOCKLEY, 

ETC., ET^., ETC. 



J?fitlalyel|5!iia : 

ED. BARRINGTON & GEO. D. HASWELL. 

NEW YORK -J. & H. G. LANGLEY: CHARLESTON, S. C.-WM. H. BERRETT: 

RICHMOND. VA. — SMITH, DRINKER & MORRIS: 

CINCINNATI, OHIO — J. A. JAMES. 

1842. 






^ 



r^ 



[Entered, according to Act of Congress, in the year 1841, by Barrington 
& Haswell, in the Clerk's office of the District Court for the Eastern District 
of Pennsylvania.] 



S^'t>T\ 



• ^ "^ Graves, Robert J[ameS] 1796-1853. 

\ % ^?_ Clinical lectures, by Eobert J. Graves ... 2d American 
^ed., with notes and a series of lectures, by W. W. G-erhard 
... Philadelphia, E. Barrington & Gr. D. Haswell; New 
York, J. & H. G-. Langiey; [etc., etc.] 1842. 

560 p. 23'='". 

"Originally published in the weekly periodicals of London." — Preface. 



1. Medicine, Clinical. i. Gerhard, William Wood, 1809-1872. 

^m 6-29620t 

Library of Congress RC46.G77 



PREFACE 

BY THE AMERICAN EDITOR 



The Clinical Lectures of Dr. Graves, which were originally 
published in the weekly periodicals of London, were first printed 
m their present form in the American Medical Library. They 
have excited so much interest in this country, and contain so much 
practical and interesting matter, that a new edition was thought 
advisable. 

The publishers of the present Edition thought that a few notes 
and some additional lectures would not lessen the value of the 
work, and requested the American Editor to republish a few of 
the Clinical Lectures given by him at the Philadelphia Medical 
Institute, and at the Philadelphia Hospital, as a part of the 
Clinical Course of the University of Pennsylvania. The circum- 
stances which attended the publication of this edition restricted 
the number of these Lectures, and increased the disadvantages 
under which they appear, as compared, and, it is feared, contrasted 
with the Lectures of Dr. Graves. An apology seems necessary 
for the style as well as the substance of the Lectures ; with a few 
exceptions they were not written by the author, but were noted as 
they were delivered, and afterwards corrected, so that they are 
hona fide Clinical Lectures. The Lectures which were given at 
the Philadelphia Hospital contain some expressions which would 
not be readily understood without a knowledge of the mode of con- 
ducting the Clinical Course. The clinical wards are contiguous to 
the lecture-room, and the patients are carried into it on their beds ; 
the remarks upon their case are made in their presence, or imme- 



4 PREFACE. 

diately after they are removed, if the disease be of a nature to render 
the prognosis doubtful, or if any other circumstances make it im- 
proper to speak before the patient. The class is too numerous to 
accompany the physician in his visits. 

The Lectures which were given at the Philadelphia Institute 
were conducted much in the usual way ; the pupils followed the 
visit, and noted the symptoms and treatment; the clinical com- 
ments and resume were made in another place. 



CONTENTS 



GRAVES'S CLINICAL LECTURES. 



LECTURE I. 

General Observations .......... page 13 

LECTURE IL 

Case of chronic cough — Remarks on bronchial secretion — Expectoration never per- 
formed during sleep — Effects of catarrhal attacks frequently recurring — Account 
of remedies employed — Great power of nitrate of potash, combined with tartar 
emetic, in subduing inflammation — Observations on the secretion of air from the 
mucous membrane of the intestines in certain pulmonary affections — Efficacy of 
sulphur in chronic bronchitis — Sensation of tickling which precedes cough — 
Cough from worms — Hysteric cough — Pulmonary irritation from a syphilitic 
taint — Pulmonary irritation connected with a gouty diathesis ; with a scorbutic 
habit : with scrofula 24 



LECTURE m. 

Sleeplessness — Sleeplessness from anxiety, grief, etc. — Case of jaundice accompanied 
by sleeplessness ; treatment — Remarks on purgative mixtures — on the proper time 
for administering opiates — Sleeplessness in delirium tremens — Chronic variety of 
delirium tremens ; treatment — Sleeplessness in fever; case — Failure of different 
modes of treatment — Use of opiate injections — Delirium traumaticum — Constitu- 
tional irritation from blisters ; treatment — Sleeplessness in hypochondriacs and 
hysterical females — On the use and abuse of cold applications to the head j , 38 

LECTURE IV. 

Gangrene and pleuritis — Hepatization of the lung — Erysipelas . 51 

LECTURE V. 

Case of suspected thoracic aneurism — CEdema of left arm and left side of the face ; 
probable cause of — Relations of the left vena innominata to the arch of the aorta — 
Reasons for concluding that the symptoms are produced by a solid tumour ; its 
Effects explained — Another remarkable case of thoracic tumour related — Case of 

1* 



CONTENTS. 

violent and extensive pulsation of the heart depending on cerebral disease — Laen- 
nec's error concerning the indications for bleeding ; case illustrative of; use of digi- 
talis in such cases — Case of asthma, and treatment — St. John Long's liniment — 
Dropsy created by opium — Acupuncturation in anasarca . . . p. 61 



LECTURE VI. 

Case of secondary symptoms which made their appearance soon after a mercurial 
course ; method of treatment — Case of syphilitic eruption — Mouth suddenly affected 
by a small quantity of mercury — Effects of this on the progress of the cure — Ear- 
ache preceded by rigors coming on during the course of fever ; danger of; treatment; 
— External tenderness : value of, as a symptom in inflammations of brain, lungs, 
abdomen, &c., &c. — Vomiting considered as a symptom in fever; its treatment — 
Chronic rheumatism; successful treatment of — Obstinate case of arthritis ; cure of 
by local applications — Observations on the effects of mercury apphed locally — Case 
of syphilitic iritis ; action of belladonna in 73 



LECTURE VII. 

General remarks on the pathology of paralysis — Dr. Graves's new views upon this 
subject — Their application to the study of several varieties of paraplegia — Expla- 
nation of Mr. Stanley's cases of paraplegia ; of Dr. Stokes's cases — Two cases of 
paraplegia after enteritis — Paraplegia after metritis — Paraplegia the consequence of 
poisoning by lead ; by arsenic — Paraplegia arising from irritation of the urethra 
(case communicated by Dr. Hutton) ........ 84 



LECTURE Vm. 

Paraplegia • .98 

LECTURE IX. 

Case of peritonitis and enteritis terminating in fatal convulsions — Enormous accumu- 
lation of lumbriciinthe bowels, producing death by convulsions — Causes of catarrhal 
affections of the bronchial tubes — On the rales produced by bronchitis — Eemarkable 
proportion between the frequency of the pulse and the respiration — Use of emetics 
and chalybeates in chronic bronchitis — Symptoms which contra-indicate chalybeates 
— Trismus from inflammation of the temporal muscles — Pain in the nerves of the 
face, simulating tic douloureux, and caused by a carious tooth — Case of jaundice, 
with remarks — Connection between arthritis, jaundice, and urticaria — Analogous 
series of affections often caused by eating fish llf> 



LECTURE X. 

On bed sores in fever, and their treatment — Instances of fever spreading by contagion 
— Attacking a person whose mouth was affected by mercury — Observations on the 
use of tarter emetic in fever — An account of the manner in which it is usually em- 
ployed — New views upon .this subject — Practice first introduced by Dr. Graves of 
giving tartar emetic, combined with opium, in the advanced stages of fever — Success- 
ful cases — Treatment of fever with profase sweating in the commencement — Mr. 
Cookson's case — !Mr. Stephenson's case — Mr. Knott's case . . . . 124 



CONTENTS. 



LECTURE XI. 

General account of the spotted fever epidemic in Dublin, in 1834-5 — Its most remark- 
able features — Insidious character — Further explanation of the reasoning which led 
Dr. Graves to the discovery of the utility of tartar emetic in its latter stages — Dr. 
Nolan's remarkable case of enteritis, with collapse, cured by enormous doses of 
opium — Cases of singular proportions between the frequency of the pulse and of 
respiration — Case of acute oesophagitis p. 135 



LECTURE Xn. 

Persesquinitrate of iron in chronic diarrhoea — Blueness of the fingers and toes in fever 
— Some account of the yellow fever which prevailed in Dublin in 1827 — Newly ob- 
served affections of the thyroid gland in females — Its connection with palpitation ; 
with fits of hysteria — Erysipelas — Remarks on the formation of acidity of the sto- 
mach in indigestion — Psoriasis — Treatment by arsenic .... 144 



LECTURE Xm. 

Case of long continued nervous fevers; remarks on — Pleuro-pneumonia — Cases of 
latent pleurisy ; of pneumonia — phthisis ; latent ulceration of the bowels in — Diar- 
rhcea of phthisis — Observations on the stammering of paralytic persons — Its expla- 
nation — Very remarkable case of stuttering cured by chronic laryngitis — Treatment 
of hoarseness — Velpeau's new method of treating sore throat . . . .158 



LECTURE XIV. 

Amaurosis — Acetate of lead in cholera 170 

LECTURE XV. 

Case of phlebitis — Remarks on the symptoms and treatment of this disease — Patho- 
logy of phlegmasia dolens — Its treatment — Case of cancrum oris — Fatal termina- 
tion — Remedies employed — Case of ague cake — Observations on the different 
varieties of ague — True ague, or intermittent fever — Ague produced by inflam- 
mation of internal organs — Nervous ague — Hysterical ague — Treatment of ague 
cake .180 

LECTURE XVI. 

Nervous fevers — Chorea — Paralysis agitans — Diabetes . ». . 190 

LECTURE XVII. 

Scarlet fever — Blisters and stimulants in fevers — Dropsy ; treatment » . 200 

LECTURE XVIII. 

Scarlet fever — Gastric constitution — Nervous fever . » . . . ''^l ^ 



8 CONTENTS. 

LECTURE XIX. 

Scarlatina p. 219 

LECTURE XX. 

Treatment of fever — Retention of urine .230 

LECTURE XXL 

Double pneumonia ■— Abscess of the heart — Chronic laryngitis — Prurigo . 240 



SECOND SERIES 



LECTURE L 

Introduction — Connection between diseases of different organs; between arthritis, 
jaundice, and urticaria ; between periostitis, produced by abuse of mercury, and 
hypertrophy of the liver — Details of cases illustrating this connection — Its expla- 
nation — Hypertrophy of the liver produced by scrofula — Enlargement and inflam- 
mation of the liver after scarlatina — Importance of recognising this disease . 252 



LECTURE n. 

Connection between disease of the liver and disease of the heart — Chronic hepatitis, 
from this source, curable in young persons — Enlargement of the spleen connected 
with superficial ulceration of the legs — Erysipelas and gangrene, sometimes of a 
pseudo-inflammatory character — Treatment of this form of disease . . . 260 



LECTURE III. 

Erysipelas in an epidemic form — Symmetrical spread of erysipelas on the body — 
Maculated fever, and Irish typhus — Dr. Lombard's remarks — Improved treatment 
of fever — Choice of a pi'oper nurse and assistants — Air of the sick chamber — 
Necessity of attending to diet and nourishment ..<.... 269 



LECTURE IV. 

General treatment of fever — Dietetic management — The starvation system may pro- 
duce organic disease — Proper food for fever patients and convalescents — Allaying 
of thirst — Sedatives — Expergefacients — Efficacy of green tea in a case of nar- 
cotism — Flagellation effectual in a case of poisoning with opium . , . 278 



CONTENTS. 



LECTURE V. 

Treatment of typhus fever — Tympanites often the consequence of inattention to diet, 
or to overdosing with purgatives — Thirst in fever frequently dependent on the state 
of some internal organ — Blisters, employed as stimulants or evacuants, excite the 
vital action of the capillaries — an important remedy where cerebral affection is ap- 
prehended — Signs of approaching cerebral symptoms — Tartar emetic solution, and 
ointment — The latter used with success in some desperate cases . . v. 286 



LECTURE VL 

Further remarks on the treatment of fever — Management of delirious patients — Ad- 
vantages of tartar emetic in the form of enema — Subsultus tendinum sometimes 
from disturbance of the nervous extremities, independently of the brain or spinal 
cord — Vomiting and purging at the commencement of fever, indicative of cerebral 
affection — Scrofulous inflammation of the brain — Chronic scrofulous fever . 295 



LECTURE VIL 

Scarlatina without eruption, followed notwithstanding by desquamation — Thoughts 
on the nature of desquamation — Latent scarlatina, followed by anasarca ' — General 
proposition respecting the symptoms of animal poison — Morbid appearances after 
delirium in fever — Treatment in anticipation of cerebral symptoms — Great advan- 
tage of blisters judiciously employed — Notice of the old mode of blistering . 302 



LECTURE Vm, 

Glanders and button-farcy in the human subject — Particulars of a case of glanders, 
with the post-mortem appearances — Remarks on the variety of skin diseases produced 
by the introduction of an animal poison into the system — Case of button-farcy — 
Analogous appearances, where, as in typhus, an animal poison is sometimes gene- 
rated in the body — Furuncular inflammation, or carbuncle, generated by animal 
poison ; also tubercles ■ — Sometimes a preternatural whiteness precedes the purple 
hue of mortification — Remarks on phlegmasia dolens — Phlegmasia dolens of the 
eye 313 



LECTURE IX. 

On the use of emetics at the commencement of fever ; not so well adapted to a later 
period — Domestic remedies for feverish colds ; these colds prove to be fevers, and 
time is lost — Protest against the abuse of purgative medicine in fever — The idea 
of curing fever by purging is absurd — Treatment where the bowels have become 
almost paralysed from the cure of preceding diarrhoea— Venesection as a means of 
checking fever — Beneficial even within the first twelve hours after seizure by typhus 
— Various cautions respecting leeching and cupping-glasses — Mode of applying 
leeches when pneumonia or hepatitis supervenes on fever . . , . 322 



LECTURE X. 

Abdominal aneurism — Effect of posture on the bruit de souffiet — Limitation of this 
sound to one spot in aneurism — Its extension in mere nervous affections — Letter 
from Dr. Corrigan on the subject — Case of diabetes — Discovery of casein in the 
urine — Different varieties of diabetes ........ 332 



10 CONTENTS. 



LECTURE XI. 

Fever — Application of cold to the head ; particular apparatus for this — Warm ap- 
plications recommended — Use of mercury in fever — Effects of intemperance — 
Illustrations afforded by particular cases — Necessity of active attention to cerebral 
symptoms — Occasional absence of morbid appearance after death — Contraction 
and dilatation of the pupils — Coup de soleil p. 341 



LECTURE XIL 

On constitutional inflammation in general — On fugitive swellings and pains — Curi- 
ous case of erratic gout causing transient swellings — Gout affecting the lobe of the 
ear — Fatty hypertrophy of the ears — Gouty grinding of the teeth — Gouty neuralgia 
of the skin — Remarks connected with Dr. Kingston's recent researches on con- 
sumption 349 



LECTURE XIIL 

On paralysis in general — On paralysis depending on affections spreading from the 
extremities of the nervous system to its centre — Gouty ramoUissement of the 
spinal marrow ; two remarkable cases of — History of this hitherto undescribed 
form of disease 357 



LECTURE XIV. 

Gout may affect the spinal marrow — Combination of arthritic inflammation with bron- 
chitis — Effects of various remedies, particularly mercury — effects of this in chronic 
bronchitis — Dr. O'Beirne's plan of rapid mercurialisation in certain affections of the 
joints — Application of the same method to inflammation of the lungs of scrofulous 
character — Cases in illustration 367 



LECTURE XV. 

Hydricdate of potash in rheumatism — Sarsaparilla and nitre in chronic cough — Re- 
marks on percussion — Clear sound with solidified lung — Fever with cerebral irrita- 
tion — Employment of tartar emetic and opium — Success of turpentine . . 375 



LECTURE XVI. 

On the efficacy of tartar emetic and opium in fever with much cerebral disturbance ; 
illustrated by cases 382 



LECTURE XVII. 

Supervention of other diseases on fever — Description of a peculiar form of low 
neuralgic inflammation, not identical with phlebitis — Local affections with morbid 
poison producing cutaneous eruption — Vesicles of Colles . . . .389 



CONTENTS. 11 



LECTURE XVIII. 

Dropsy following scarlatina ; utility of bleeding — Albuminous urine not necessarily 
the result of diseased kidney — Pulmonary affection after fever ; smilax aspera — 
Phlegmasia dolens not dependent on phlebitis; treatment — Case of metritis — 
Melsena ; various kinds of black discharge from the bowels ; green stools not always 
a sign of deranged liver . - p. 399 

LECTURE XIX. 

On the influenza — Course and progress — Effect of climate, locality, &c. — Mor- 
tality — Peculiarities of epidemic of 1837 — Symptoms — Singular case with 
hernia 408 



LECTURE XX. 

Influenza continued — History of the symptoms — Stethoscopic phenomena — Post- 
mortem appearances — Extent to which the nervous system is implicated — Charac- 
ter of the sputa — Appearances of the urine — Cerebral affections — Bleeding ony to 
be employed at the onset — opiates in conjunction with antimony or nitre — Blis- 
ters generally inefficient — Warm fomentations beneficial . . . .418 



CONTENTS 



GERHARD'S CLINICAL LECTURES, 



LECTURE I. 



Acute articular rheumatism — Connection with inflammation of the cardiac mem- 
branes. — Treatment, bleeding, opiates, &c 431 



LECTURE IL 

Continuation of acute rheumatism. — Rubeola, or measles, in adults and children — 
Symptoms — Complications — Treatment 439 

LECTURE III. 

Inflammations of serous membranes — Pathological anatomy — General symptoms. — 
Pleurisy. — Tuberculous peritonitis, etc • • 447 



12 CONTENTS. 



LECTURE IV. 

Acute inflammations of the membranes of the heart. — Pericarditis. — Endocar- 
ditis . . . . ' p. 457 

LECTURE V. 

Tubercular meningitis. — Case. — Anatomical characters. — Symptoms . . 465 

LECTURE VI. 

Peritonitis from cancer of liver. — Acute Meningitis. — Diagnosis — Symptoms — 
Treatment 474 

LECTURE VIL 

Chronic meningitis. — Apoplexy. — Paralysis of the insane .... 484 

LECTURE VIII. 

Apoplexy and inflammation of the brain (continued). — Functional diseases of the 
brain 492 

LECTURE IX. 

Delirium Tremens. — Symptoms. — Stages. — Varieties. — Complications. — Treat- 
ment 499 

LECTURE X. 

Dysentery. — Varieties. — Diagnosis. — Anatomical lesions. — Treatment . .510 

LECTURE XL 

Sub-acute dysentery (continued) — Pathology and treatment. — Phthisis pulmo- 
nalis 517 

LECTURE XIL 

Phthisis pulmonalis. — Pathological characters of gangrene of the lungs . . 534 

LECTURE XIII. 

Phthisis pulmonalis (concluded). — Cases. — Treatment . , . . .539 

LECTURE XIV. 

Pneumonia. — Jaundice. — Tubercular meningitis. — Pathology of laryngitis and 
laryngeal phthisis 543 

LECTURE XV. 

Typhus and typhoid fever. — Symptoms. — Treatment . . . .551 



CLINICAL LECTURES. 



FIRST SERIES. 



LECTURE I. 

GENERAL OBSERVATIONS. 

Gentlemen : — As it is usual, at the commencement of a course 
of clinical instruction, to devote the first lecture to a consideration 
of some general topics connected with the line of studies most 
proper to be pursued by those who wish to attain eminence ; I 
have, in compliance with this custom, thought it right to lay before 
you some observations on the proper mode of studying physiolog}' 
and morbid anatomy, with a view of showing how best to derive 
advantages from these accessory but necessary sciences, — sciences 
which, according to the manner in which they have been culti- 
vated, have, at different periods, retarded or advanced that most 
important of all branches of professional knowledge, practical medi- 
cine. It is quite evident, that a knowledge of the functions and 
structure of the body in health is essential to him who undertakes 
the treatment of disease, and hence physiology has always occupied 
the attention of physicians. Physiology, however, may be studied 
in very different ways, and witii very different objects ; and, until 
lately, all those who were engaged in the cultivation of this fasci- 
nating science, not contented with observing the state of the dif- 
ferent parts and tissues during health, the nature and quality of the 
secretions, the mechanism and operation of the different organs, 
sought to ascend from a knowledge of effects to an investigation of 
causes, and, after they had classified the more obvious phenomena 
of living bodies, endeavoured to ascertain, if not the very principle 
of life, at least those motions and causes of motion which result 
immediately from the action of the living principle. Having thus, 
as they conceived, obtained a more accurate knowledge of the con- 
ditions of health, they proceeded to form general explanations of 
the causes of disease, and frame general rules for their removal. 
This method, apparently so philosophical, and possessing so many 

2 



14 GRAVES'S CLINICAL LECTURES. 

attractions from the generality and simplicity of its application, has, 
more than any other circumstance, contributed to retard the pro- 
gress of medicine. Gentlemen, this is not only an ancient, it is also 
a modern evil. We live among systems. It is true, that the prac- 
tice, founded on the mechanical, mathematical, chemical, and hu- 
moral physiologies, has been long since abandoned ; but the de- 
structive system of Brown has not long quitted the stage, where its 
place is occupied on the continent by those of Broussais and Rasori, 
and in Great Britain by the system which derives all diseases from 
derangement of the digestive functions, or from inflammation. 
Physiology legitimately embraces, not the study of vital actions, 
but merely aims at ascertaining and arranging their effects. The 
important facts which its study discloses, are perhaps infinite in 
number. As long as we confine ourselves to these we advance at 
every step, and all is clear and intelligible; but the moment we 
attempt to inquire into the causes and modes of vital action, we 
begin to retrograde, and all becomes hypothesis and confusion. 
Thus, an examination of the organ of sight discovers a w^onderful 
and beautiful optical arrangement, calculated to form on the retina 
a picture of external objects, exact both in its colouring and outhne. 
The physiologist, examining with attention the different parts of 
the eye, and the laws of their respective refractions, investigates the 
means by which distinct vision is secured at different distances; he 
compares the human eye and its appendages with that of animals 
which live in water, those which soar into the highest regions of 
the atmosphere, and those which burrow under ground. He con- 
siders the eye of the mole, feeble but protected against injuries 
likely to be encountered in carrying on its subterraneous works; 
of the eagle who, poised high in mid-air, selects its victim from the 
distant pasture; of the fly, whose microscopic organ, with a range 
of vision scarcely exceeding the limits of contact, distinguishes ob- 
jects the most minute ; and in all he finds variations in the optical 
instruments at once curious and intelligible. But when he endea- 
vours to advance further in his inquiry, and tries to explain how 
an image, painted on the retina, produces vision, whether by the 
means of undulations arising from the rays of light, and propagated 
along the optic nerve to the brain, or whether because the retina is 
a nervous expansion, highly organized and framed, so as to feel the 
coloured image painted on it, he is at once arrested in his progress 
by the barrier which is everywhere interposed between physical 
and vital actions, between the mechanism of the organs of sense 
and the mode in which they produce ideas between body and 
mind. 

But has he, therefore, gained no real knowledge applicable to 
practical purposes, or has his time been merely spent in a pleasing 
but useless study ? By no means ; — being acquainted with the 
mechanism and arrangement of the optical instrument, he is often 
enabled to remedy its accidental derangement. By means of a con- 
cave glass he corrects a too speedy, by a convex a too tardy, con- 



GENEBAL OBSERVATIONS. 15 

centration of the rays of light. When the crystaHine lens becomes 
opaque, his knowledge of its connections, nature, and position, 
enables him either to remove it altogether, or to displace it from 
the axis of vision, or to promote its absorption, and, in order to 
effect the latter purpose, he mechanically irritates it, knowing by 
experience that, after such an irritation, the process of absorption 
commences, although he is quite ignorant of the connection between 
mechanical irritation and this vital process. He who inquires into 
the physiology of the brain and spinal marrow can never discover 
the nature of nervous influence, or the manneV in which pressure on 
these organs destroys, or irritation deranges, the motions of the 
voluntary muscles, and yet the entire treatment of cerebral or spinal 
diseases, whether spontaneous or from the effects of injury, is 
grounded on a knowledge of this physical fact ; without it we 
could not estimate the value or effects of morbid changes in the 
brain or spinal marrow. On this reposes the rationale of the treat- 
ment of all convulsive, paralytic, and apoplectic affections. 

Although we know not the manner in which the eighth pair of 
nerves superintends the respiratory process, although we under- 
stand not how the phrenic nerve influences the motion of the dia- 
phragm, yet a knowledge of these facts led to a relief of spasmodic 
asthma, and to the recovery of persons apparently asphyxiated, by 
means of the galvanic stimulus passed along the course of these 
nerves. Knowing that some of the nerves, distributed to the face, 
are destined for sensation, while others serve for muscular motion, 
in cases of tic douloureux we divide the sentient and not the mo- 
tive nerves. In these, and a thousand other instances, physical 
physiology supplies us with information at once interesting and 
practical ; it would be still easier to prove, as in the cases of Brown 
and Broussais, that vital physiology, by involving us in the discus- 
sion of subjects beyond the powers of our reason, never fails to en- 
tangle its votaries in a labyrinth, amidst whose mazes they move 
without progressing, and consume in idle speculations that time 
and labour they ought to spend in the acquisition of useful know- 
ledge. But I trust the period is at length arrived when this error 
will be avoided ; for, on the whole, it must be confessed, that in 
consequence of a wrong method of studying, and a misconception 
of the true objects of physiology, this science has in many instances 
retarded the progress of practical medicine. 

Let us next consider the connection of morbid anatomy with 
practical medicine. Many have mistaken the end and object of 
morbid anatomy, and there are not wanting some who even deny 
its utility, v/hile others again, in their zeal for its improvement, 
have endeavoured to extend its limits, so as to make it comprehend 
and embrace in the explanations it affords all the phenomena of 
disease. It is not easy to determine which of these parties has 
most injured the cause of practical medicine. Morbid anatomy 
comprehends not merely decided and permanent structural altera- 
tion,-but embraces, so far as they are capable of being detected, 



16 GRAVES'S CLINICAL LECTURES. 

even temporary physical changes in internal organs. In order 
justly to estimate its importance, we should recollect that the first 
alteration in the texture of a part is not the cause but the conse- 
quence of disease, for in every healthy organ the texture is natural, 
and as every change of texture is produced in consequence of de- 
rangement in the vital action of the vascular system of the part, it 
is obvious that structural alteration must, in the first instance, be 
always produced by functional derangement. Thus, the physical 
alterations which attend external inflammation — the tumefaction, 
the heat, the redness, are not the causes but the consequences of 
disease. But in thus reducing them to the rank of symptoms, do 
we diminish their importance ? Certainly not. For being imme- 
diately connected, as effects, with the primary cause, they prove 
the most useful of all symptoms, in enabling us to ascertain the 
seat and progress of diseased action. In this respect they possess 
a manifest advantage over the general or constitutional symptoms. 
Thus, in cases of spontaneous gangrene, phlegmonous inflamma- 
tion, or erysipelas, what practitioner would be contented to draw 
his indications from the general symptoms, disregarding the appear- 
ance of the affected part? And yet this is exactly what those per- 
sons do, who refuse the aid of morbid anatomy in the treatment of 
internal disease. 

In external diseases most of the physical changes in the affected 
part can be at once recognised ; their diagnosis is therefore compara- 
tively e^sy, and their treatment well established. In internal diseases 
the case is widely different, the physical alterations are here beyond 
the cognisance of our senses ; and, in order to ascertain their nature 
and situation, we must carefully compare the morbid appearances 
of internal organs, as revealed to us by dissection, with the symp- 
toms during life. Although alteration of structure is in the first 
instance produced by a disease in the vital action of the part, yet 
this structural alteration may itself become a new cause of mischief. 
Thus the vascular system of the lungs, from some unknown cause, 
assumes such a change of action as produces a deposition into the 
pulmonary texture of various fluid and solid products, by which 
the entrance of the air into its vesicles is prevented, and the respir- 
atory function, one of the most important of the body, is thus con- 
siderably deranged. Again, whatever be the original vital derange- 
ment which causes scirrhus of the pylorus, the obstruction thus 
formed is a secondary cause of new and important symptoms. 
Another consideration, whifth enhances the value oif morbid ana- 
tomy, arises from the fact, that when diseased action fixes itself in 
any part of the body, whether external or internal, and there gives 
rise to physical alterations, experience teaches us, that the progress 
of the disease may be often arrested by removing its eflfects. Thus, 
to recur to the example of external inflammation, the redness, the 
swelling, the heat of the part are but symptoms, and yet we find 
great benefit from the applications of remedies capable of diminish- 
ing them ; hence we leech, and apply cold lotions, etc. From all 



GENERAL OBSERVATIONS. 17 

these considerations it is evident, that whenever disease is attended 
with either a temporary or a permanent aheration in the tissue of 
an internal organ, it will be of the greatest practical importance to 
ascertain the nature and extent of that alteration, and the progress 
of practical medicine will be exactly proportioned to the accuracy 
with which this can be accon)piished. Thus, how much has the 
treatment of pectoral diseases been improved by the application of 
auscultation and percussion, means which are only useful by en- 
abling us to ascertain the physical alterations induced by the 
disease, or, in^ other words, the morbid anatomy of the affected 
organ. Without their aid, how trace the progress and follow the 
increase or diminution of pulmonary inflammation? — how demon- 
strate the existence of dropsical or pleuritic effusion within the 
chest? — how distinguish with certainty pleurodyne from pleurisy? 
I could prove the utter impossibility of distinguishing many cases 
of bronchitic from tubercular phthisis without their assistance. I 
might refer to chronic emphysema of the pulmonary tissue, a dis- 
ease of great importance, but actually unknown before the time of 
Laennec, who first accurately described it in the dead body ; indeed, 
before the application of percussion and auscultation, a perfect 
knowledge of this derangement of the pulmonary structure in the 
dead body would not have assisted our diagnosis, for how recog- 
nise it during life? I might bring forward dilatation of the bron- 
chial tubes, another disease wholly unknown before Laennec's 
time, and which, before his discovery, could not be recognised by 
the common method of observation. I might enlarge upon the 
great utility of attending to the changes which take place within 
the chest in measles and scarlet fever, but the benefit resulting from 
an accurate acquaintance with the morbid anatomy of the thoracic 
cavity is now so generally acknowledged, that I shall rather choose 
my illustrations from other classes of diseases. 

Nosologists, until very lately, were agreed in attributing consid- 
erable frequency' to those cases of apoplexy and paralysis which 
arise from serous effusion into the brain, or from a mere functional 
inaction or debility of the cerebral and nervous systems. This 
opinion was founded partly on speculative grounds, and partly on 
inadequate and imperfect post-mortem examinations, and in prac- 
tical books the symptoms supposed to announce sanguineous, serous, 
and nervous apoplexy, were dogmatically laid down. What was 
the consequence? — Most disastrous, as I have had occasion to wit- 
ness, in some parts of the continent, where the elderly practitioners 
still adhered to the practice founded on this false pathology. What 
can be more melancholy than to see time wasted or misemployed 
in the exhibition of diuretics, to promote absorption of the serum 
effused into the brain, or of strong exciting remedies, such as 
arnica, camphor, etc., to overcome the nervous debility, in cases 
where copious depletion by the lancet and purgatives were urgently 
necessary. I do not deny that in some rare cases effusion into the 
brain is the cause of sudden death from apoplexy. I have seea 

2* 



18 GRAVES'S CLINICAL LECTURES. 

such an event supervene in. chronic dropsy, but there the termina- 
tion was very sudden, and the state of the case left no doubt as to 
the cause ; but in the majority of the cases formerly treated as 
serous or nervous apoplexy a more careful examination would 
have detected marks of vascular excitement, or local inflammaiion,. 
a subject I shall treat at large when on the pathology of the brain. 
A similar error in morbid anatomy led to a similarly erroneous 
practice in the treatment of hydrocephalus, and many cases of 
general and local dropsy. The effusion occupied the sole attention 
of pathologists ; the marks of preceding vascular excitement or 
inflammation escaped their notice. 

Tim.e will not permit me to enlarge upon the light which morbid 
anatomy, rationally pursued, has shed upon diseases of the brain. 
It is sufficient to remark, that some of the most important modifica- 
tions of inflammation in that organ have been only lately discovered, 
and it is only lately that a minute and extensive examination of the 
different changes the brain undergoes in diseases has begun to intro- 
duce a certain degree of re^rularity and precision into a department 
where all before was confusion and inaccuracy. Examples of the 
utility of morbid anatomy might be brought forward without num- 
ber: — the discovery of local inflammation being at times the cause 
of a disease in most of its symptoms resembling common ague ; the 
use of the lancet in the cold stage of ague, a practice which may 
be advantageously resorted to, in cases where each return of the 
fit is accompanied by a recurrence of inflammation in a vital organ, 
as the lungs or brain ; the connection between inflammation of the 
mucous membrane of the stomach, and some of those symptoms of 
fever formerly attributed to mere debility ; the influence of cerebral 
inflammation and congestion, in producing the symptoms formerly 
vaguely denominated typhus; the low character which fever as- 
sumes when accompanied by pneumonia (and that, too, often 
latent) ; the symptoms which are produced by follicular ulceration 
of the intestines, which so frequently occurs in the course of fever; 
the diagnosis between the pain produced by neuralgia of the abdo- 
minal nerves, and that resulting from structural diseases of the 
intestinal canal; a more accurate knowledge of the state of the 
mucous membrane in the diarrhoea of phthisis, and in intestinal 
tympanitis; the numerous improvements in the treatment of dis- 
eases of the ear, which followed Itard's investigations concerning 
the morbid anatomy of that organ; — these and many other disco- 
veries, all replete with practical advantages, are the results of the 
attention of our contemporaries to morbid anatomy; and, were I 
to appeal to the records of surgery, I might bring forward examples, 
if not more important, perhaps more evident and striking; for the 
invention and success of most capital operations depend on a per- 
fect knowledge of the structural derangements, the removal or cure 
of which is attempted. Of this, examples suggest themselves on 
every side, but none is more striking than the one devised by 
Dupuytren for the cure of artificial anus, the most disgusting and 



I 



GENERAL OBSERVATIONS. 19 

loathsome malady to which human nature is subject, and deemed 
altogether incurable, until that excellent surgeon, by a combination 
of profound pathological and physiological knowledge, succeeded in 
planning and executing an operation, that were alone sufficient to 
immortalise his name.* 

The study of morbid anatomy, however, is attended with no 
ordinary difficulties, and, when imperfectly understood, is liable to 
lead to erroneous results, for it requires much candour, much 
patience, and that experience which can be only acquired by long 
continued practice, to enable us to judge concerning diseased 
appearances. The power of accurately discriminating in the dead 
body the traces of disease cannot be suddenly acquired, and so 
numerous are the various errors to which superficial observers are 
liable, that much injury has thus resulted to medical science, dis- 
eased appearances being in some cases overlooked, and in others 
recorded where they did not exist. Those who are aware how 
often the congestion,, which frequently takes place immediately 
before or after death,, in the pulmonary tissue, in the mucous mem- 
brane of the lungs and alimentary canal, and who know how often 
this congestion alters the physical properties of these parts, so as 
almost exactly to simulate the vestiges of inflammation, will under- 
stand how it happens that in investigations connected with the 
real or supposed diseases of these parts, facts have been marshaled 
against facts, and observations arranged against observations, until 
the path which promised simplicity and order terminated in per- 
plexity and confusion.. Hence the doctrines of Broussais received 
so many corroborations, and appeared to rest upon a numerous 
series of undoubted and well-authenticated facts. 

The morbid anatomist must of all things beware of seeing too 
much. He must avoid imposing on himself by everywhere seeing 
exactly what he expected to see, and above all things let him not 
always force himself to see something ; for many diseases proceed 
to a fatal termination without having produced any evident morbid 
alteration. 

When I come to treat of the pathology of the brain and nervous 
system, I shall have occasion to advert to errors which late authors 
have committed from too great an anxiety on the one hand to reduce 
to a certain and definite system the morbid appearances of the brain 
and spinal marrow, as connected with their diseases, and, on the 
other, to find, in every case where the cerebral or nervous functions 
had been diseased, lesions of structure to account for the symptoms. 
Thus, to cite one of numerous instances, I shall have occasion to 
prove that epilepsy and mania often commence suddenly and vio- 
lently, without the existence of any organic alteration ; and, in- 
deed, that organic lesions are not necessarily connected with these 
formidable diseases is sufficiently proved by the occasional sudden 
manner in which they cease. Thus, a gentleman of great literary 

* [He was preceded, however, by the late Dr. Physick of Philadelphia, — i^c?.] 



20 GRAVES'S CLmiCAL LECTURES. 

reputation was many years a patient of mine before his death, 
which happened in 1831, at the age of seNrenty. From the age of 
tweniy-five to fitU'-fire he suffered from violent and frequently 
recurring fits of epilepsy ; after having continued thirty years the 
disease ceased suddenly, without any assignable caase, and for the 
lasi fifteen years of his life he had not a single fit I shall have 
occasion to show you how fine-drawn and how iU-foanded the 
observations of those who profess to account for every Derrous dis- 
turbance during life by cerebral lesions, who profess to distingaish 
accurately during life inflammation and irritation of the arachnoid 
or dura mater from irritation or inflammation of the brain itself, 
who maintain that one series of symptoms is produced by inflam- 
mation of the cortical, and another by inflamnaatioo of the medul- 
lar}, substance, who have strained their eyes to discover, and their 
veracity to impose upon us, proofs that inflammatory or other dis^ 
eased states of certain portions of the brain caused invariably 
similar affections of certain mental functions. These errors of 
some, even of the most eminent French pathologists, it will be my 
duty to notice from time to time ; bat I am sorry to say that much 
more unpardonable errors and mis-statements have found their way 
into English and Irish publications on the pathology of the braiu. 
and which I shall be compelled to speak of hereafter. 

Having made the preceding observations on the dangers which 
arise from an ill-directed application of the studies of physiology 
and morbid anatomy to the practice of medicine and surgery, I feel 
myself imperatively called on to present the other side of the ques- 
tion to your view, in exposing the still more dangerous doctrioe 
advocated by those who depreciate the value of pathology and 
morbid anatomy as only instructive after the death of the patient, 
and even then as not unfrequently calculated rather to mislead 
than to advance the interests of practical medicine. 

It must be conceded, that he who is only a physiologist, cannot 
hope to cure disease, and that the mere morbid anatomist will be 
often misled by post-mortem appearances, if he has not attentively 
w atched the progress of symptoms, and the effects of medicines, 
during life : for, unless this be done, he will, as I have already said, 
often mistake secondary for primary lesions, will confound effects 
with their causes, and wdll refer to certain alterations of structure, 
that which had originated in a functional disorder, a morbid state 
of parts very different from that which is observed after death. 
But when, to an accurate knowledge of physiology and morbid 
anatomy is joined an extensive observation of the progress of symp- 
toms, and the efiects of therapeutical agents, how much more 
certain and satisfactory will be our practical decisions, and how 
much more likely our efforts to be attended with success, than if 
we merely studied disease at the bed-side of the patient. In the 
latter case, we might, indeed, become expert uosologists, be accu- 
rately acquainted wiih certain groups of symptoms, and even not 
unfrequently adopt the proper method of treatment. These symp- 



GENERAL OBSERVATIONS. 21 

toms, considered together, we would call by a certain name, and 
hand down to posterity this new acquisition of medical knowledge, 
perhaps clothed in the garb of a dead language, and invested with 
the false dignity of a learned tongue. But what have we really 
thus effected for posterity ? Our follovi^ers read our definitions of 
disease with an acquiescing admiration, and, sure of the efficacy of 
the remedies we have recommended, they go forth with an over- 
weening confidence in quest of the group of symptoms we have 
described, and when they have met with them, they look upon 
their task as already half accomplished, and promise a successful 
termination of the disease. " Tell me the name of the disease," 
was the motto of the nosologist, " and I will tell you the remedy;" 
but, gentlemen, I will engage to tell you the names of a hundred 
diseases, without your being able to name the proper method of 
treatment. I tell you a man has dropsy, his limbs are anasarcous, 
water is accumulated in the peritoneal cavity, his urine is scanty, 
and his thirst increased. Will you, from this very excellent noso- 
logical definition, venture to prescribe for this case of dropsy ? For 
the sake of the suffering patient, and your own conscience, pre- 
scribe not on such data. And yet I regret to be obliged to say, 
that such a method of procedure is by no means rare, nay, it is 
even a matter of daily occurrence. But this case of dropsy will 
not yield. Some other boasted specific hydragogue or diuretic is 
had recourse to ; still the patient grows worse and worse, and 
finally dies, but his friends are not discontented with the medical 
attendant, who excuses himself by asserting that he has succes- 
sively resorted to every remedy which has been recommended in 
dropsy; and, in truth, if you look over the list of medicines exhi- 
bited in rapid succession, you will probably find that his excuse is 
not unsupported by facts. But these cases in which every thing 
has been tried, are exactly those in which nothing has been tried, 
in which medicine has followed medicine, and each symptom of 
disease has indiscriminately been the object of attack, until death 
approaches with accelerated step, and charitably closes a scene dis- 
tressing to humanity, and disgraceful to the cause — 1 was going 
to say — of science ; but who will venture to give so ennobling a 
name to this pseudo-practical knowledge — - thi*s worse than absolute 
ignorance ? 

Gentlemen, I am not combating phantoms; I do not. Quixote- 
like, contend with imaginary giants: no, what I have described, 
exists; the picture I have drawn has many an original. But let us 
have done with this subject ; let us turn to the gratifying consider- 
ations of the progress which practical medicine is making under its 
parent science — physiology and morbid anatomy. 

The reason of man is now more fully employed than at any 
former period, a vast store of mental power, a vast mass of mind, is 
everywhere at work; what formerly was vainly attempted by the 
labour of a few, is now easily accomplished by the exertions of the 
many. The empire of reason, extending from the old to the new 



22 GRAVES'S CLINICAL LECTURES. 

world, from Europe to our Antipodes, has encircled the earth — the 
sun never sets upon her dominions — individuals must rest, but the 
collective intelligence of the species never sleeps : at the moment 
one nation, wearied by the toils of day, welcomes the shades of 
night, and lies down to seek repose, another rises to hail the light 
of morning, and, refreshed, speeds the noble work of science! 

All inquiries commence, as it were, at the same point, as the 
labours of their predecessors are equally at the disposal of all, and, 
consequently, it is not surprising we should often find them arriv- 
ing together at the same end; thence the numbers of simultaneous 
discoveries of the same fact now so common. It is not unusual to 
find the publications of France, German}^ Italy, and England, 
simultaneous]}^ announcing the same discovery, and each zealously 
claiming for their respective countrymen an honour which belongs 
equally to all. I am sorry to say that, with some splendid excep- 
tions, this interesting and innocent controversy has been carried on 
by other countries, while Ireland has put in no claim for a share of 
the literary honours awarded to the efforts of industry or genius. 
But, gentlemen, I hope that this state of inaction, this state of 
mental torpor, has ceased, and that the time has passed away when 
we could not point out among our brethren any who had advanced 
the boundaries of the medical sciences, and thus promoted the inter- 
ests of humanity. Already have the names of several of the senior 
members of the profession been spread abroad ; already has the 
scientific character of this city been elevated by such men as Dease, 
Blake, Colles, Carmichael, Cusack, Crampton, Marsh, and Kirbj; 
and already have some of the junior members of the profession 
attached their names to discoveries which shall be commemorated 
as long as anatomical sciences are cultivated ; I need scarcely add 
that I allude to the names of Jacob and of Houston. The interest- 
ing descriptions given by these gentlemen of their respective disco- 
veries, in a department of human anatomy in which all further dis- 
covery was looked upon as hopeless, are probably know^n to you 
all, and therefore it is unnecessary now to enlarge upon them. 
Neither have we, at present, leisure to enter into the no less inter- 
esting field of investigation which Dr. Corrigan has opened, by 
the publication of his experiments on the sounds and ' motions of 
the heart — experiments leading to conclusions so novel, that most 
physiologists were at first incredulous, and many even ventured 
boldly to call into question their accuracy. Without, at present, 
venturing to decide whether Dr. Corrigan's opinions be in every 
respect correct, 1 may assert that his paper is wTitten in the true 
spirit of philosophical'inquiry, and that he deserves opponents of 
a far higher grade than those who have endeavoured to refute his 
arguments in the English periodicals. 

With regard to the treatment of disease, we must not omit the 
discovery, by Mr. Carmichael, jun., of this city, of the curative 
effects of spirits of turpentine in iritis; for although we were in 
possession of two valuable reaiedies for the cure of this disease, 



GENERAL OBSERVATIONS. 23 

belladonna and mercury, yet there are cases in which it is useful 
to be able to accomplish a cure without the aid of salivation. 

It is with feelings of the greatest satisfaction and pride, that I 
claim the right of adding to this list the names of three gentlemen, 
whose friendship I have long enjoyed, Mr. Adams, Mr. M'Dowell, 
and Dr. Stokes. Of the two former, it is unnecessary to speak, 
their contributions to science are so well and so duly appreciated. 
Concerning the latter, my colleague. Dr. William Stokes, I shall 
impose upon myself an unwilling and constrained silence, partly 
because his merits claim a warmer and longer eulogy than would 
suit this time and place, but chiefly because his labours have placed 
him in a position, as far elevated above the necessity of praise, as 
above the fear of censure. Neither shall I allow myself to eulogise, 
as they deserve, the talents and exertions in the cause of science 
rendered by Professors Apjohn, Harrison, Kane, Montgomery, and 
E. Kennedy. They all rank high among the successful cultivators 
of some of the most useful departments connected with our art; 
their names, associated with those already enumerated, form a cata- 
logue the subject of congratulation for the present, of happy augury 
for the future, for cold must be the breast of him who will not hail 
with joy every symptom of our country's literary regeneration, dead 
the feelings which are not elated at the boon conferred on our 
species by every advance made by those who devote themselves to 
the grand, the noble pursuit of relieving the suffering, of healing 
the diseased; but time bids me stop: I shall, therefore, conclude by 
observing that the attention lately devoted to the distinctions be- 
tween real and pseudo morbid appearances, the diligent cultivation 
of m.orbid anatomy by men not the slaves of preconceived opinions, 
the abandonaient of all systems whose baseless fabric rests on the 
phantoms of vital physiology, the importance now justly attached 
to medical statistics, to the study of endemic and epidemic mala- 
dies, to the operation of morbid poisons : these, and various other 
circumstances, give us reason to hope that the progress of the 
human mind, in investigating the means of preventing and curing 
diseases, will not be less rapid than it has been in the other depart- 
ments of knowledge ; and thus it will be proved, that if man has 
passions which impel him to the destruction of man, if he be the 
only animal who, despising his natural weapons for attack or de- 
fence, has devised new means of destruction, he is also the only 
animal who has the desire, or the power, to relieve the sufferings 
of his fellow-creatures; the only animal in whom the co-existence 
of reason and benevolence attests a moral as well as an intellectual 
superiority. 



24 GRAVES'S CLERICAL LECTURES. 



LECTURE II. 

Case of chronic cough — Remarks on bronchial secretion — ExpcctOTation never per- 
formed during sleep — Effects of catarrhal attacks frequently recurring — Account 
of remedies employed — Great power of nitrate of potash, combined with tartar 
emetic, in subduing inflammation — Observations on the secretion of air from the 
mucous membrane of the intestines in certain pulmonary affections — Efficacy of 
sulphur in chronic bronchitis — Sensation of tickling which precedes cough — 
Cough from worms — Hysteric cough — Pulmonary irritation from a syphilitic 
taint — Pulmonary irritation connected with a gouty diathesis; with a scorbutic 
habit ; with scrofrila. 

Allow me to direct your attention to-day to the case of J. Jowson 
in the chronic ward, labouring under an attack of exasperated 
chronic bronchitis — a disease which derives its chief importance 
from the circumstance of being exceedingly common. There is 
no morbid affection of the system more frequent or more general 
than chronic bronchitis ; it is of every day occurrence in dispen- 
sary practice ; it is one of those cases which you will be constantly 
called on to treat ; and hence the study of its nature and treatment 
has strong claims on your attention. 

This man is, as you have seen, about the middle age in point of 
years, but he is old in constitution. In this country you will find 
most of the labouring poor exhibiting symptoms of premature old 
age — the combined result of poverty, intemperance, and hardship. 
Obliged to work in the open air in bad weather, they get catarrhal 
affections, which are renewed by repeated exposure, and prolonged 
for want of proper care. The natural effect of cold frequently 
renewed and generally neglected is, that a tendency is produced in 
the bronchial mucous membrane to become congested and inflamed 
with facility, until at length the derangement becomes permanent, 
and the mucous membrane no longer returns to its normal and 
healthy condition during the intervals. 

The secretion of the mucous membrane of the bronchial tubes, 
in a perfectly healthy person, is almost entirely destitute of matter 
to be expectorated. In the normal state, the secretion of thd bron- 
chial mucous membrane, though continually going on, scarcely 
ever exists in superfluous quantity, for a certain proportion of it is 
carried off* by exhalation or absorption ; a perfectly healthy person, 
breathing a pure air, has no expectoration whatsoever. The 
moisture secreted by his bronchial mucous membrane contains 
nothing that the expired air cannot carry away in vapour, without 
leaving any residuum which, gradually accumulating, would at 
length require to be expectorated. In this respect the bronchial 
mucus in the healthy state differs from the mucus of other mem- 
branes of the same class ; but disease destroys this beautiful pro- 
vision; and gives rise to a secretion of morbid mucus which cannot 
be gotten rid of in the usual way, and which must therefore be 
expectorated. Hence it is that persons, in whom a chronic state of 



CHRONIC BRONCHITIS. 25 

congestion of the bronchial membrane has been generated by re- 
peated colds, have a secretion of superfluous matter always going 
on, and are constantly expectorating. This may continue for seve- 
ral years without much inconvenience ; the principal annoyance 
the patient suffers is in getting up the phlegn.i in the morning. At 
this period there is always an accumulation of fluid in the lungs 
after the night, during which the cough is less frequent, and expec- 
toration less copious. 

Here let me remark, that, although a person may cough violently 
during his sleep, he never expectorates. Expectoration is accom- 
plished by the attention being directed to the chest, by an act of 
volition being put in force, so as to cause a constriction of the 
bronchial tubes, and generate a current of air of sufficient strength 
to expel the mucus. To efl^ect this, the mere act of coughing is 
not sufficient, and consequently we do not expectorate during sleep ; 
for this purpose it is necessary for the patient to be awake. 

Frequently recurring catarrhal affections, besides generating a 
state of chronic derangement of the mucous lining of the lungs, 
have a necessary tendency to produce other bad effects. Dyspnoea 
is an ordinary attendant on chronic bronchitis; the vesicular tissue, 
enfeebled by disease, loses its natural elasticity; and-hence the act 
of respiration is performed weakly, and with considerable diffi- 
culty. In addition to this, the stress thrown on the air cells and 
passages gives rise to emphysema and dilatation of the bronchial . 
tubes. 

When this man came into the hospital, he was labouring under 
an exacerbation of his chronic bronchitis, from a fresh attack of 
cold ; he also suffered from dyspncea with a tendency to emphy- 
sema, and had been much debilitated by the frequent recurrence of 
his pulmonary symptoms. I do not intend to make any particular 
observations here on acute bronchitis supervening on chronic; it 
is a dangerous disease, requiring prompt and careful attention. I 
merely refer to this case to point out the remedies. which were em- 
ployed, and the principles which guided me in their selection. 

At the time of our patient's admission, the fever which accom- 
panied the acute attack had subsided. His pulse was tolerably 
quiet, neither did he present any derangement of the heart's action, 
and, so far, had escaped one of the consequences of chronic disease 
of the lung — namely, dilatation and hypertrophy of the right ven- 
tricle. Observe, the most important features in this case, so far as 
treatment is concerned, were these : there was no general inflam- 
matory condition of the system present; he had neither hot skin 
nor quick pulse ; his expectoration was copious : the chest sounded 
well on percussion, and the only stethoscopic phenomena observed 
were extensive minute and moist bronchial rales. The case then 
stood thus: extensive bronchial inflammation with copious expec- 
toration, unaccompanied by fever, and occurring in a debilitated 
constitution. All w^eakening measures were therefore contra-indi- 
cated. It is true that the man had dyspnoea, and complained of 

3 



26 GRAVES'S CLINICAL LECTURES. 

tightness across his chest — circumstances which might appear to 
demand the use of the lancet or leeches; if these means had been 
employed, he would certainly have experienced some relief; but in 
the course of a few hours the symptoms of distress would have 
returned, the weakness superinduced by bleeding would give rise 
to increased secretion into the bronchial tubes, and the patient 
would be worse than before. Under these circumstances, we re- 
frained from using the lancet or leeches ; but, deeming it advisable 
to get rid of the last traces of inflammatory action, we gave the 
following mixture : — <■ 

R MistursB amygd alarum, ^xij., 

Nitratis potassas, Jijv 

Tartar, emetici, gr.j., 

Tinctur. opii camphorat., .f ss. 
Ft. mistura pectoralis, sumat cochleare ]., amplam orani hora, vel urgent© 
tusse. . . 

In explaining the rationale of this mixture, it is hardly necessary 
for me to state why the almond emulsion was used. In all cough 
bottles it is of importance that the basis should consist of some mild 
mucilaginous fluid ; and hence we generally employ for this pur- 
pose demulcent syrups, emulsions made with olive oil, spermaceti, 
or almonds, or decoctions of mucilaginous seeds and roots. With 
the almond emulsion we combined tartar emetic and nitrate of 
potash — both antiphlogistic remedies, and calculated to act with 
peculiar effect in relieving congestion of the bronchial mucous 
membrane. You are aware that nitrate of potash in large doses is 
a powerful antiphlogistic, and you have seen it prescribed with 
excellent effects in cases of acute arthritis treated in this hospital. 
Nitrate of potash, when given to the amount of two or three drams 
in the day, combined .with two or three grains of tartar emetic, is, 
next to bleeding, the most efficient means we possess of reducing 
inflammatory action ; and were I to be asked what remedies I should 
employ in combating inflammation — supposing there were no such 
things as the lancet, or leeches, or calomel — I should certainly say- 
nitrate of potash and tartar emetic. When given in small doses 
this combination proves also extremely serviceable in less severe 
cases, and it was on this account we gave it in the present instance. 
To this we joined the camphorated tincture of opium, convinced 
that its stimulant properties could not prove injurious when com- 
bined with antiphlogistics, ahhough it would be improper to admi- 
nister it alone. Experience has taught that when camphorated 
tincture of opium is given, in cases of chronic cough with expec- 
toration, it will (if much inflammatory action be present) check the 
expectoration, and bring on dyspnoea. But when combined with 
nitrate of potash and tartar emetic, its bad effects are corrected, 
while its sedative influence remains unimpaired. 

In addition to this, I ordered the nitro-muriatic acid liniment to 
be rubbed over his chest. This liniment we are much in the habit 



CHRONIC! BRONCHITIS. 27 

of prescribing where a rubefacient is required. It is made by dili- 
gently mixing one dram of nitro-muriatic acid and one ounce of 
lard, by means of a wooden or ivory spatula. When this mixture 
is complete, two drams of spirits of turpentine are added ; these 
ingredients soon separate from, and mutually react upon each 
other, so that the liniment is spoiled; we, therefore, never make it 
in large quantities. As his bowels were constipated, I gave him a 
pill composed of three grains of blue pill, quarter of a grain of col- 
chicum, two grains of .scammony, and half a grain of capsicum. 
Colchicum acts on the biliary secretion, particularly when combined 
with blue pill, and hence promotes the general action of the intes- 
tines. With these I combined a little capsicum, in consequence of 
the patient's complaining of being annoyed by constant flatulence, 
it is a curious fact, that every chronic derangement of the bronchial 
mucous membrane is accompanied by flatulence. Whether this 
arises from the irritation of the bronchial membrane spreading by 
continuity of tissue, and rendering the tongue foul, the stomach 
weak, and the digestive function unnatural; or whether the de- 
rangement of the bronchial mucous membrane, and the imperfect 
performance of the function of respiration, causes the secretion of 
air from the lungs to be diminished, in consequence of which air 
is secreted from the intestinal mucous membrane by a vicarious 
action — I cannot exactly state, but I think the latter hypothesis not 
very improbable. It is well known that the mucous membrane of 
the stomach and bowels enjoys the power gf secreting and absorb- 
ing air; it secretes carbonic acid, nitrogen, and also other gases 
which seem peculiar to it — such as sulphuretted hydrogen. I am 
not aware that there is any distinct evidence that the last-named 
gas is ever secreted by the bronchial mucous membrane, but, as 
there are some cases in which the breath is remarkably fetid, I 
think it remains for future experiments to decide whether it may 
not be so under certain circumstances. It is, however, by no means 
improbable, that when an adequate cause produces considerable 
derangement in the respiratory function, and alters the nature of 
the aerial secretion from the lung, the mucous lining of the stomach 
and bowels may take on a vicarious action, and secrete gases ana- 
logous to those which in the normal state are secreted by the mucous 
membrane of the bronchial tubes. I think I have seen some well 
marked examples of this translation of the function of secreting 
air from the pulmonary to the intestinal mucous system in cases of 
spasmodic asthma and hysteria. I have seen patients who, pre- 
viously to an attack of asthma, had no symptoms of flatulence, and 
observed that, accordingly as the disease proceeded and the derange- 
ment of the respiratory function increased, the bowels became dis- 
tended with air. In hysteria, also, where derangement of the 
respiratory function is plainly denoted by the heaving of the chest, 
sighing, and dyspnoea, there is generally enormous and sudden 
inflation of the belly, loud borbyrygmi are heard, and there is a 
constant disengagement of air upwards and downwards. 



28 GRAVES'S CLINICAL LECTURES. 

But to return to our patient. After we had removed all traces of 
active inflammation, and the case had been, reduced to one of ordi- 
nary chronic bronchitis, we changed his cough mixture for the fol- 
lowing : — 

R Misturse ammoniaci, ^vj. 

Carbonatis sodas, '^ss. 

Tincturae opii camj)horat., ^ss. 

hyoscyami, ^j- 

Vini ipecacuanhas, 5ij' 
Fiat mistura pectoralis, sumat. cochl. j. amp. pro dose. 

The carbonate of soda was given with a view of removing some 
acidity of stomach which he complained of; besides, it is a fact 
that alkalies produce good effects in many cases of pulmonary irri- 
tation, as must have struck you from witnessing the success of the 
popular remedy for hooping-cough, recommended by Mr. Pearson. 
You will observe, gentlemen, how very different this cough mixture 
is from the former, it is much more stimulating, and, at the same 
time, more powerfully anodyne, the opium being here less diluted, 
and being aided by henbane; the addition of ipecacuanha w^as in- 
tended to prevent a too speedy action on the part of the other ingre- 
dients, in diminishing the expectoration and constipating the bowels. 

I wish to call your attention to the plan of treatment, not with 
reference to this case alone, but with respect to chronic bronchitis 
in general. We first gave a combination of nitrate of potash and 
tartar emetic, with the view, of removing any remaining traces of 
inflammatory action; we next prescribed the misturas- ammoniaci, 
with camphorated tincture of opium and carbonate of soda, etc. ; 
and, finally, when the cough became entirely chronic, we gave the 
compound iron mixture, with tincture of hyoscyamus, in draughts, 
and an electuary, consisting of sulphur, cream of tartar, and senna. 
I need not repeat what you will find in every treatise on materia 
medica, with respect to the use of the compound iron mixture ; it 
is not to be given until all traces of fever and local inflammation 
are removed, and never until the secretion from the lungs is copious, 
and expectoration free. In such cases, the patient is generally weak, 
and the inordinate secretion adds to his debility. Here the compound 
iron mixture proves extremely serviceable, but you should com- 
mence its use with caution. Some person^ are in the habit of 
giving it in doses of half an ounce, two or three times a day ; this I 
never do; I begin with a dram, twice or three times a day, in an 
ounce of spearmint water, and add from half a dram to a dram of 
tincture of hyoscyamus. The dilution with mint water, and the 
addition of tincture of hyoscyamus, render it more valuable, by 
causing it to be more easily borne by the system, and less likely to 
be rejected by the stomach. 

Let me now explain my reasons for ordering the following 
electuary ; — 



CHRONIC BRONCHITIS. 29 

B Electuarii sennas, 5iij. 

Pulveris supertart. potasses, ^ij. 

Sulphuris loti, gss. 

Syrupi zingiberis, q. s. 
Ut fiat eiectuarium, sumat cochleare, j. parvum bis vel ter quotidie. 

In the first place, when giving any stimulant medicine internally, 
it is essentially necessary to attend to the state of the bowels ; in 
the next place, keeping the bowels freely opened, has a very re- 
markable eftect in diminishing inordinate secretion from the bron- 
chial tubes. Where the patient's strength can bear it, I often 
diminish supersecretion from the lung by strong hydragogue pur- 
gatives, as you saw in the case of a patient in the chronic ward, 
w^ho had orihopnoea, and such an excessive secretion into the bron- 
chial tubes as to threaten suffocation. The patient being a strong 
man, and having no symptom of intestinal irritation, I prescribed a 
bolus, composed of a grain of elaterium, two of calomel, ten of 
jalap, and live of scammony, forming a powerful hydragogue pur- 
gative, which produced several fluid discharges. The man bore 
its operation well, and I repeated it in two days with the most 
decided benefit; indeed, he experienced from it more complete 
relief than he would have done from bleeding, blistering, or any 
other remedial means. In some cases of bronchitis with excessive 
secretion, you will be able to produce very striking effects by the 
use of hydragogue purgatives : this, however, will require both 
judgment and disci-Btion, and it should be borne in mind, that, in 
the majority of cases, there are many circumstances which contra- 
indicate their employment. 

With respect to the use of sulphur in this case, I was led to pre- 
scribe it, in this and many other similar cases, from observing that 
chronic cough, and long-continued congestion of the bronchial 
m.ucous membrane, were more efl^ectually relieved by the use of 
sulphureous waters, such as theLucan and Harrowgate Spas, than 
by any other remedy that could be devised."* I may here also 
observe, that the Lucan waters produce very striking effects in dis- 
eases of the skin, and that I have seen intractable cases of psoriasis, 
which lasted for years, yield to the use of the Lucan waters. It 
would appear that sulphur, when taken into the system, is either 
ehminated by the kidneys in the form of sulphates, or exhaled 
from the skm and mucous tissues in the form of sulphuretted 
hydrogen, and in this way we arrive at some explanation of its 
action in diseases of the skin, and chronic irritation of the bronchial 
mucous membrane, hi fact, paradoxical as it may appear, sul- 
phur, although evidently stimulating, is nevertheless very effica- 
cious in curing many diseases connected with, or depending on^ 
inflammation or congestion. Thus exhibited internally and pro- 

* [May not this be the cause of the great celebrity enjoyed by the Red Sulphur 
Spring of Virginia, which although a weak is a very pure sulphureous water, and 
is certainly beneficial in chronic irritations of the bronchial and alimentary 
mucous membranes, — Ed.] 

3* 



30 GRAVES'S CLINICAL LECTURES. 

perlj combined, ^^hat remedy gives such prompt and certain relief 
in that painful affection, piles? How rapidly does the specific irri- 
tation of the skin, termed scabies, yield to its use ! These, and 
similar facts, which might be brought forward in abundance, ought 
to countenance the use of this medicine in certain chronic inflam- 
matory affections of the bronchial tubes. The celebrated Hoffman 
was in the habit of adding sulphur to his cough prescriptions in all 
cases of chronic bronchitis in the aged and debilitated ; and I have 
no doubt that from five to ten grains of sulphur, taken three or four 
times in the day, is one of the best remedies that can be prescribed 
in cases of chronic cough, accompanied by constitutional debility 
and copious secretion into the bronchial tubes. Within the last 
four years, my attention has been particularly directed to the use 
of sulphur in this and other affections, and I can state from expe- 
rience that it is a most valuable remedy. As it has a tendency to 
produce elevation of the pulse, increased heat of skin and sweating, 
it will be necessary to temper its stimulant properties by combin- 
ing it with cream of tartar, which is a cooling aperient, and has the 
additional advantages of determining gentlv to the kidneys.* The 
addition of the electuary of senna gives additional value to the com- 
bination, and quickens its action on the intestines. 

Such, gentlemen, are the principles that guided me in prescribing 
for this man. The long continuance of the complaint, the serious 
and extensive derangement of the pulmonary mucous membrane, 
the age, debility, and impoverished circumstances of the patient, 
forbid me to hope for a perfect cure ; but he has been much relieved, 
and the same remedies applied to less desperate cases would have 
produced very striking effects. Siill, if fortune were this moment 
to prove favourable to the poor fellow, if, when lie leaves the hos- 
pital, instead of returning to hardship and exposure, he had the 
means of living in comfort, taking proper care of himself, traveling 
for health and amusement, and using a course of chalybeate spa 
waters, I have little doubt that v/ith these aids the reparative powers 
of nature would succeed in obliterating every trace of pulmonary 
derangement. 

Permit me, gentlemen, to make a few observations here on what 
is popularly termed, cough. What is cough ? A sudden and 
violent expulsion of air from the lungs, produced by forcible con- 
traction of the diaphragm, aided by the abdominal and other ex- 
piratory muscles. What is the cause of cough 7 Pulmonary irri- 
tation. What is the nature of this pulmonary irritation ? 

Here, gentlemen, is a question which every practitioner should 
put to himself when called on to treat a case of cough, and what 
affection is there which so frequently demands our assistance, and 
tasks our ingenuity ? How abundant, how varied, are the examples 
of cough we meet witli in our dailv practice ! How^ obscure do we 
not find its nature on many occasions, and how difficult and per- 

* Baglivi has well said, "In morbis pectoris ad vias urinoe ducendam est." 



CHRONIC BRONCHITIS. 31 

plexing its treatment! Where the source of irritation is manifest, 
where the nature of the disease is simple and easily detected, where, 
■after a proper examination, we can point to some part of the respir- 
atory system, and say here is the seat of the disease ; in such cases, 
indeed, our course is sufficiently clear ; we may proceed with con- 
fidence, and practise with success. But how often are we, after 
weeks and even months of close and painful attention, baffled in 
our best-directed efforts, and forced to admit the humbling convic- 
tion that all our remedies are inefficient and useless, and that our 
character, as well as that of the profession, is likely to suffer in 
public estimation ! How often, too, do we discover with surprise, 
that the cough which we have b*een treating for weeks as a pure 
pulmonary affection, depends not on any primary derangement of 
the respiratory system itself, but upon the irritation of some distant 
•organ, or upon peculiar conditions of the whole economy! 

Before I proceed to inquire into the nature of the various sources 
of pulmonary irritation producing cough, I wish to remark that the 
exciting cause, or, in other words, that which immediately precedes 
and seems to give rise to atendency to cough, is a sensationof tickling 
in the mucous membrane of the trachea, close to its bifurcation, and 
opposite the hollow at the fore part of the neck. It is also a curious 
fact that this sensation of tickling or itching is peculiar to this situa- 
tion, being never felt in any other part of the pulmonary mucous sys- 
tem. Whether the disease be seated above, as in case of laryngeal 
affections, or whether it be below, as in case of disease of the lining 
membrane or parenchyma of the lung, it is here alone that the tick- 
ling sensation is felt. Another circumstance equally remarkable, 
and equally difficult of explanation, is the effect of position in cough. 
Persons labouring under slight bronchitis, or rather slight inflam- 
mation of the trachea, who scarcely cough half a dozen times in the 
course of the day, will, the moment they lie down at night, be seized 
with a violent and harassing cough, which may last for several 
minutes, and sometimes for hours, with little intermission. We can 
easily understand .why empyema or pneumonia of one side of the 
chest may produce cough in certain positions and not in others, for 
here we have an obvious physical cause; the accumulated fluid in 
the pleural cavity in the one case, and the diseased lung, whose 
specific gravity has been much increased by solidification, in the 
other, exercise an inconvenient degree of pressure on the sound 
lung, and hence give rise to irritation and cough, particularly in 
those positions which favour the operation of these physical causes 
of irritation. Here, however, the cause of irritation is very obscure. 
It may (but this I merely offer as an hypothesis) depend on the 
fluid secreted by the mucous membrane trickling over that part of 
the trachea where the tickling sensation is felt, the flow of mucus 
to this part being favoured by the recumbent position. That it 
•does not depend on any supposed temporary congestion and irrita- 
tion of the lung, from the impression made on the skin by cold 
bed-cloih'es, I am quite convinced, for I have repeatedly observed 




S2 GRA.VE8^ CLD?!€AL USXTTUSES. 

it in persons warmly dressed, from merely Ijii^ domi oo a sohi 
close to the fire. Yoa will, therefore, bear 
tiOAt although usDallj, wlteai coaghing Is iioidlaioed by smj 
change of position, une may infer that it is ooomectBd wMi 
serious. lesion of the longs or pleura, yet we must not atttach too 
niQch importance to this symptom in arrmi^ at fhb oondliiBsioii, 
for cases are occasionally met with/iii wiuch meie tiacheal or 
bronchial infiammation is attended with the saioe symptom to a 
very remarkable degree. 

I may -observe, en passant, that ' ■ f ^:t- vataonrf tki^i^ or ftdb- 
ing appears to be almost esclusivf ■ ,-^a^ to fhe dam. 'Heie 

it appears to be dependec: : :. : r : iraajily incapable of 

producing that modificati : :. : r. e : \ : ; i : :^ jm famed pain. In 
other cases it seems to be connected wiflli the nse and decline of 
the phenomena which ^!rd:'-"^*^ ^":^''"^'^^"^:^ry action, aiiang in the 
fct case (where it is r : : . : ~ aide) finim that nerwoas 

modification which pre'-;e^e£ .nzizizi^: ' in the second bdi^ 

connected with some change in the et .he part which pie- 

cedes its return to a :. ; - : •. appearto aflect 

the mucous tissues, ei . : t _ ; ^ . itTtt : iid Taiwlerpecn- 

iiar circumstances. It is ; : trved m : 7 : ?rymncoaB 

tissue, except at that pari ci ^^.& ;:aehea wiiiC^ 1 : 7 ■ e^^y mca- 
tioaed, and it does not occur in mjowfisatei thr 7 :.ucoos 

membrane. The only parts connected " '' ' : 7 : r . „ : -: . :n 
which it is felt, are the nose and on ihf ■ : t : f 

the reach of scratching, th'e ordiuE'" ••; : :7 : : . i 7 7 
tunate circumstance, gent]en:en. :'.: .: ::■' .;-.: 
were to itch as 3-our skin 5 ; f s does, line annoj: : 

quite intolerable. If the piesiLie of lumhiici in i:.7 : 
tines, instead of producing a troublesome itchiiag of -.7 
often does, — if it produced, I say, a degree of itching f : 
in the mucous membrane of the bowels and sitoma-c;: 
could end ure greatt : - - ^ •; : ; - - --■::-. f ; :~ 
ascarides gave rise ; : :i : i .7 ;. -7^ 77 ;. : _■ 
colon, as they o::l? :z :: ;::e 'f r^ ;; : 7 1 _r 
would be the sVif^t:v:.z : : ; : :. i-ii- . 

Passing over the c . : ::i well know:. : : : 7 : 

irritation, prodcT ::,:>., suc^ ~~ '*:■:■ 7. 

the first cause t; -^ _. : 1 shall di: i . 
unfrequent occDrre::;7 : : ~ berx^ a i-ni£l^£e m iUar:-. 
to a practice useless i : atient and discredit's: 

titioDer. The br5: :: ixiustralii^ thb is : : .. 

detail of a case " ::.::. I :..;iDded with Dr. She r 
lady, residing in the neighbourhood of Doraet 5 .- 7 i 
wilii symptoms of violent and alarming bironcaiLiS. 
cooghing went on for hours with extraordinary inHeii^! 
dr}\ extremely loud, hollow,, and repeated every five c: 
nigfat and day, when she was asleep as well 
awake. Its violence was soch that it 



CHRONIC BRONCHITIS. 33 

but expressive phrase, to tear her chest in pieces, and all her friends 
wondered how her franne could withstand so constant and so terri- 
ble an agitation ; and yet she fell not away proportionally in flesh, 
had no fever, and her chest exhibited nothing beyond the rales 
usually attendant on dry bronchitis. She was bled, leeched, blis- 
tered, and got the tartar-ennetic mixture, but without experiencing 
the least relief. We next tried antispasmodics, varying and com- 
bining them in every wa}^ our ingenuity could suggest, still no 
change. We next had recourse to every species of narcotics, ex- 
hibiting in turn the various preparations of conium, hyoscyamus, 
opium, and prussic acid, but without the slightest benefit. Foiled 
in all our attempts we gave up the case in despair and discontinued 
our visits. Meeting Dr. Shekleton some time afterwards I inquired 
anxiously after our patient, and was surprised to hear that she was 
quite recovered and in the enjoyment of excellent health. She had 
been cured all at once by on old woman. This veteran prac- 
titioner, a servant in the family, suggested the exhibition of a large 
dose of spirits of turpentine, with castor oil, for the purpose of re- 
lieving a sudden attack of colic ; two or three liours afterwards the 
young lady passed a large mass of tape worm, and from that mo-' 
ment every symptom of pulmonary irritation disappeared. 

The next kind of cough, in which the cause of pulmonary irrita- 
tion is often misunderstood, is that which occurs in hysteric females. 
This kind of cough is one of the most alarming diseases in appear- 
ance you can possibly witness ; in some it is loud, ringing, inces- 
sant, and so intensely violent, that one wonders how the air-cells, 
or blood-vessels, escape being ruptured. In others it is quite as 
incessant, occurring every two or three seconds, night and day, 
but is not very loud, and, indeed, in some it scarcely amounts to 
more than a constant teazing hem ; in general the pulse is quick, 
but it is the quick pulse of hysteria, not of inflammation or fever. 
The patient suffers no aggravation of the cough from inspiring 
deeply, and her countenance exhibits no proof of malaeration of 
the blood, on the contrary it is blanched and pallid. She com- 
plains of variable or deficient appetite, headache, cold feet, and 
irregular or absent catamenia, although the cough continues for 
weeks, or even months, she does not emaciate like a person in 
incipient phthisis, although so much disturbed by the cough, and 
subsisting on so small a quantity of food. 

Here the history of the case, a knowledge of the patient's habit, 
and the use of the stethoscope, are of great value. You will find 
ihat tlie patient is subject to hysteria, that she is generally pale and 
of a nervous habit, that the attack came on suddenly, and was 
superinduced by mental emotion, or some cause acting on the 
nervous system, or else arose gradually as one of the sequelse of 
catamenial disturbance, that the heat of skin and state of pulse are 
'by no means proportioned to the violence of the symptoms, and 
the stethoscope will tell jou that the signs of organic derangement 
6>f iiae lung are absent. You will thus be enabled to arrive at an 



M GRAVES'S CLINICAL LECTURES. 

accurate notion of the natore of the disease, and yoa will save the 
patient from the useless and often dangerous employment of anti- 
phlogistic means. Bleeding and leeching are, generally speaking, 
injurious ; such cases are best treated by stimulants, antispasmodics, 
and stimulant purgatives, together with the change of air, traveling, 
and the use of chalybeate spa waters.* 

The third species of obscure cough, to which I shall direct your 
attention, is one of deep importance for many reasons* It is that 
species of cough which depends upon pulmonary irritation con- 
nected with a venereal taint in the system. That syphilis may 
attack the pulmonary as well as the cutaneous, osseous, mucous, 
and other tissues, is not a discovery of modern times: it is a form 
of the disease long known, and you will find it mentioned by many 
of the old writers. Since syphilis has been classed by Willan and 
others among diseases of the skin, this notion seems to have been 
either abandoned t)r forgotten, but, as it strikes me, with very Kttle 
justice. I entertain a fim conviction, that syphihs mayaifectthe 
pulmonary as well as it does the cutaneous, or mucous, or osseous 
tissues : and that a patient, labouring under a venereal taint, may 
have irritation from this cause set op in the lung as well as in any 
of those organs in which it is usuaKy manifested. The first per- 
who mentioned this circumstance to me was the late Mr. 
and since that time I have had repeated opportunities of 
coi^EBii^ the truth of his opinion. Richter, Alibert, and Paget 
irave well observed, that Willan and Bateman's classification of 
diseases of the skin is liable to the paramount objection, that it has 
no reference to the constitutional origin of cutaneous affections. I 
have the very same fault to find with modem treatises on diseases 
of the lungs. Pathologists have indeed acquired most accurately 
into the numerous morbid changes to which tlie pulmonary tissue 
is subject, but they have omitted a no less important part of their 
task, which is to investigate the state of constitution which origi- 
nated these changes. The agency, indeed, of scrofula has been 
inquired into with care, but how little attention has been paid to 
rheumatism, gout, syphilis, and scurvy, the finiitful sources of nu- 
merous diseases of the chest. 

By far the most interesting point connected with this affection 
is its diagnosis ; on this every thing depends. The great import- 
ance attached to the diagnosis arises from the circumstance of this 
disease presenting sympt,oms analogous to, and consequently being 
frequently confounded with, phthisis. A patient comes to consult 
yon for cough : you find him pale, emaciated, and feeble : he sleeps 
badly, and is feverish at night, and has a tendency to sweat. Here 
there may be a double source of error. If the disease be mistaken 
for tubercle, and mercury not given, bad consequences wift result : 



* [I haTe known a case at this kind yield imfwwiiattjy to a seton in the nucha 
after almost all remedies had failed. Bat no ooe remedy is at all certain ; 
eiialybeates with rhabarb. vesretable tonics, and sea bathing, are the best remedies, 
fat the largest number of cases. — Ed.J 



CHRONIC BRONCHITIS. 35 

on the other hand, if tubercles be present, the effect of administer- 
ing mercury will be to precipitate the disease to a fatal issue. 

What is the nature of this disease, and how are you to recognise 
it? Mainly, I answer, by the history of the disease. If the pa- 
tient's sufferings have commenced at the period of time, after 
primary sores on the genitals, when secondary symptoms usually 
make their appearance ; if some of his complaints are clearly trace- 
able to this source; if, along with debility, night-sweats, emaciation, 
nervous irritability, and broken rest at night, we find cough ; and 
if this group of symptoms have associated themselves with others, 
evidently syphilitic — such as periostitis, sore throat, and eruption 
on the skin — then we may, with confidence, refer all to the same 
origin, and may look upon the patient as labouring under a syphi- 
litic cachexy, affecting the lungs as well as other parts. In forming 
this diagnosis much caution and care are necessary, and we must 
not draw our conclusion until we have repeatedly examined the 
chest by means of auscultation and percussion ; if these fail to 
detect any tangible signs of tubercles, we may then proceed to act 
upon our decision with greater confidence, and may advise a suf- 
ficient but cautious use of mercury. Under such circumstances, it 
is most pleasing to observe the speedy improvement in the patient's 
looks and symptoms; the fever, night-sweats, and watchfulness 
diminish; he begins to get flesh and strength, and with the symp- 
toms of lues, the cough and pectoral affection disappear. I am not 
prepared to say which of the pulmonary tissues is most usually 
attacked by the venereal poison, but I believe that it chiefly tends 
to the bronchial mucous membrane, although, like other animal 
poisons — e. g,, those of measles and scarlatina — it may also occa- 
sionally produce pneumonia. 

The fourth species of obscure pulmonary irritation, producing 
cough, is that which is connected with a gouty diathesis. Gout 
may attack almost every tissue in the body. We may have it in 
the joints, as you are all well aw^are of; we may have it in the 
muscles and muscular aponeuroses, forming what has been termed 
the rheumatic gout ; it occurs frequently in the fibrous tissues, and 
I have several times observed it in the cellular substance of various 
parts of the body, forming either diffuse oedema or tumours, which 
are exceedingly tender to the touch, and which are removed by 
treatment calculated to relieve the constitutional affection. It may 
attack the heart, giving rise to true pericarditis, or else to a func- 
tional disease with palpitations — a sensation of fluttering and sink- 
ing about that organ, and very remarkable intermission of the 
pulse ; or it may affect the stomach, occasioning dangerous spasm 
or various dyspeptic symptoms; or it may seize on the intestines, 
producing irritation, colic, and gouty diarrhoea. I remember a pa- 
tient, of a confirmed gouty habit, expressing a great deal of sur- 
prise at getting an attack of gout in the testicle, for he could not 
conceive how a disease which generally affects the joints could 
occur in an organ so different in its nature. I replied that the 



36 GRAVES'S CLINICAi: LECTURES. 

matter could easily be explaioed ; because fibrous tissue, which 
gout most frequently attacks, enters into the composition of the 
testicle as well as that of the joints. Indeed, the testicle, with refer- 
ence to the texture of its envelopes and the extent of motion it 
enjoys, may be said to be provided with a sac-like joint. In like 
manner, gout very frequently attacks the mucous membrane of the 
trachea or bronchial tubes, causing a dry, annoying, and often a 
very obstinate cough. Where this cough comes on along with the 
fit of inflammation of the joints, its true nature is frequently 
overlooked, and it is believed to have originated in cold, and to 
be mere common bronchitis. No matter what be the cause of 
inflammation in a gouty habit — no matter what the organ attacked 
by the inflammation be — it almost invariably assumes the character 
of true gouty inflammation. If a gouty person sprains a toe or an 
ankle, matters, after progressing for a time in the ordinary way, are 
sure in the end to exhibit a change of character ; and the inflamed 
parts are observed either to grow unexpectedly worse, or to become 
stationary, at a time when a speedy termination of the local affec- 
tion seemed approaching. This is owing to its being now modified 
by the constitutional tendency to gout, which localises itself in the 
affected part. Precisely the same relations may be often observed 
between common bronchitis, produced b3^cold in a gouty habit, and 
the gouty bronchitis it indirectly produces. Gouty bronchitis often 
becomes chronic, continuing until it is reheved by a regular fit of 
the gout in the extremities. 

The fifth species of ptihnonary irritation, in which the source of 
the disease is more or less obscure, is that which is connected with 
the scorbutic diathesis. It is important to be aware of this, par- 
ticularly for those who have charge of the health of the poorer 
classes, which is almost of more value than that of the rich, for oa 
it their labour and their means of support depend. Among the 
poor, particularly in cities where the majority live on salt pro- 
visions, the scorbutic diathesis is very prevalent. It manifests itself 
either in the form of purpura, or in tendencies to hemorrhage from 
the nose, stomach, bowels, and bladder. It sometimes attacks the 
lungs, producing irritation of the bronchial mucous membrane, with 
cough and spitting of blood, and occasionally gives rise to pulmo- 
nary apoplexy, h is evident that pulmonic cases of this nature, 
originating in a scorbutic diathesis produced by confined air, damp 
lodging, and a salt diet, will require a treatment peculiar to them- 
selves, both during the attack and during convalescence. 

The last source of pulmonary irritation, to which I shall direct 
your attention, is that which proceeds from scrofula. You all know 
that scrofula has a tendency to attack every tissue in the body, but 
you may not perhaps be aware that it may aflect those tissues in 
very different ways, and that scrofulous irritation may manifest 
itself in various forms, from the most trifling and transitory to the 
most extensive and permanent. I recollect a case I attended with 
Dr. Jacob, in which this fact struck me very forcibly. A fine boy, 



CHRONIC BRONCHITIS. 37 

of high complexion, precocious intellect, and other marks of the 
scrofulous diathesis, got an attack of scrofulous ophthalmia of an 
intense character, and it required all the skill and ingenuity of Dr. 
Jacob to save him from blindness. During the period of our attend- 
ance, his brother (who was also of a strumous habit) began to com- 
plain of parts of his arm being sometimes a little sore. This 
circumstance attracted my attention, and on examination I found 
that several circular diffused swellings, of various sizes, often 
equalling half a crown in diameter, had successively appeared on. 
different parts of his extremities and body. They evidently de- 
pended on inflammation of the sub-cutaneous cellular tissue, and 
exhibited a remarkable example of a most transitory local affection, 
produced by a constitutional cause — for these swellings arose, ar- 
rived at their acme, and subsided in the space of ten or twelve 
hours ; they constituted, in truth, the first efforts of the scrofulous 
diathesis to localise itself, and, after a few weeks' continuance, they 
were replaced by distinct and fixed scrofulous inflammation of the 
metatarsal bones. 

Here was a very curious and instructive fact. A boy, evidently 
of a scrofulous diathesis, has circumscribed tumours, which arise, 
come to maturity of irritation, and subside in the course of a iew 
hours. In some weeks afterwards, scrofulous irritation, in a decided 
and permanent form, fixes itself in the foot, producing inflamma- 
tion and ulceration. From this it may be inferred that scrofula 
(for in this case I am firmly convinced these tumours were con- 
nected with strumous diathesis) may attack parts not only in its 
more permanent and destructive forms, but also in a manner so 
trifling and so transitory as to subside in a few hours, and leave no 
trace of its existence. The inferences deducible from this fact are 
numerous and important ; for if scrofula may thus produce an 
acute and transitory inflammation of the sub-cutaneous cellular 
tissue, surely it may occasionally give rise to somewhat similar 
affections of internal organs — • as the bowels, the lungs, etc. — and 
thus may occasion an acute bronchitis, a pneumonia, or an inflam- 
mation of the mucous membrane of the intestines, totally indepen- 
dent of the operation of cold, or the usual causes of such affections. 
It has been too much the custom to refer merely chronic and fixed 
local inflammations to the agency of constitutional causes. The 
example before us proves that even the most transitory may have 
this origin.* 

Scrofulous irritation may affect either the lining membrane or 
the parenchyma of the lung — giving rise in the one case to scrofu- 
lous -bronchitis, in the other to scrofulous pneumonia ; two affec- 
tions which may exist separately or combined, and either of which 
may prove fatal, with or without the development of tubercles in 
the lungs. Tubercles have, as I have elsewhere proved, too exclu- 

* [There is no doubt of this ; but we cannot think that it is the custom to neglect 
this connection of acute disease with chronic cachexiae. — Ed."] 

4 



38 GRAVES'S CLINICAL LECTURES. 

sively engrossed the attention of those who have investigated the 
pathology of phthisis ; they are a very frequent product of the scro- 
fulous diathesis, but the scrofulous bronchitis and scrofulous pneu- 
monia are still more frequent and more important, and do not, as is 
falsely supposed, depend upon the presence of tubercles in the lungs. 
The pneumonia, the bronchitis, and the tubercles, where they occur 
together, are all produced by one common cause — scrofula. Of 
this more hereafter.* 



LECTURE III. 

Sleeplessness — Sleeplessness from anxiet}', grief, etc. — Case of jannclice accompanied 
by sleeplessness ; treatment — Remarks on purgative mixtures — on the proper time 
for administering opiates — Sleeplessness in delirium tremens — Chronic variety of 
delirium tremens ; treatment — Sleeplessness in fever; case — Failure of different 
modes of treatment — Use of opiate injections — Delirium traumaticum — Constitu- 
tional irritation from blisters ; treatment — Sleeplessness in hypochondriacs and 
hysterical females — On the use and abuse of cold applications to the head. 

Two cases which have been recently under treatment in this 
hospital demand your particular attention, — the man w^ho has 
been labouring under a severe attack of jaundice, and the boy who 
is recovering from fever. A remarkable symptom in both of these 
patients, and which must have repeatedly attracted your notice, 
w^as a total privation of sleep. In the former case the sleeplessness 
continued for a week, in the latter for nine or ten nights. 

Sleeplessness is a very curious result of disease. It accompanies 
certain morbid conditions of the system brought on by actual 
disease, or by grief, care, and various other forms of mental dis- 
turbance, continues to harass the unhappy sufferer night after night, 
and frequently resists the most powerful and decided narcotics. I 
do not intend to enter into any inquiry respecting the different 
states of the constitution in which it occurs ; my purpose is merely 
to offer a few practical remarks on the more obvious and striking 
examples, with the view of illustrating the cases to which I have 
directed your attention. 

There is a form of sleeplessness which is frequently the precursor 
of insanity, and which has been well described by my friend Dr. 
Adair Crawford. The watchfulness in such cases is accompanied 
by the well known symptoms of incipient mental derangement, and 
its treatment is therefore inseparably connected with that usually 
resorted to in cases of threatened insanity, and embraces the em- 
ployment of means moral as well as physical. Of these it is not 
my intention to speak ; I may observe, however, that Dr. Crawford 
has found opium, gradually increased to very large and frequently 
repeated doses so as to produce sleep, the best remedy. 

* [A most valuable practical remark, bat susceptible of more extended appli- 
cation. The acute inflammations are rarely very violent, but generally sub-acute 
and prolonged. — Ed.J 



SLEEPLESSNESS. 39 

In the case of jaundice, the patient passed several nights without 
any sleep. He was just beginning to recover from the jaundice 
when this new symptom appeared, and I directed your attention 
particularly to the circumstance, because every manifestation of 
nervous derangement connected with jaundice should be carefully 
watched. It frequently happens that jaundiced patients sleep too 
much, and in some cases the disease is accompanied by convulsions, 
succeeded by coma, most alarming symptoms, and almost invaria- 
bly the harbinger of a fatal termination. Dr. Marsh was the first 
who directed our attention to the great fatality of those cases of 
jaundice in which convulsions occur ; T have seen but one instance 
of recovery.* It was in the case of a gentleman labouring under 
icterus, very considerable hepatitis, with enlargement of the liver 
and anasarca, with ascites. He was treated by Dr. Osborne and 
myself, and had at least a dozen long and violent convulsive 
paroxysms, ending in coma, succeeded by temporary forgetfulness 
and fatuity. Repeated leeching of the right hypochondrium, active 
purgation, and mercurialisationof the system removed all the symp- 
toms of disease, and he slowly but perfectly recovered. A very 
able and original writer, Dr. Griffin, of Limerick, has detailed the 
particulars of some interesting cases of this nature in the Dublin 
Medical JournaL You perceive, therefore, that in jaundice every 
thing denoting an unusual state of the nervous system, whether it be 
too much sleep or too little, demands your attention. 

In this man's case the jaundice was the result of an attack of 
hepatitis. We treated it with leeches, blisters, and the use of mer- 
cury, and in the course of a few days the stools became copiously 
tinged with bile, and symptoms of improving health appeared. At 
this stage, the dejections being bilious, but the jaundice still remain- 
ing, he began to exhibit symptoms of restlessness and nervous irri- 
tability, and finally became perfectly sleepless. Here, gentlemen, 
we had to deal with a new symptom, extremely harassing to the 
patient, and likely to react unfavourably on the original disease. 
As a preliminary step I determined to evacuate the bowels, and for 
this purpose I prescribed a purgative draught, consisting of five 
ounces of infusion of senna, half an ounce of sulphate of magnesia, 
a dram of tincture of senna, and a scruple of electuary of scam- 
mony. My object was to purge briskly, and then give a full nar- 
cotic. In all cases of jaundice depending on hepatic derangement, 
after you have succeeded in producing bilious evacuations, you 
should never omit prescribing an active aperient every second or 
third day for the space of ten days or a fortnight, with the view of 
carrying off the remains of the disease, so as to prevent the occur- 
rence of a relapse. Hence you will find such cases very much im- 
proved by the use of Cheltenham water, taken every day for three 
or four weeks after the reajipearance of a bilious tinge in the 

* [Even stupor is a very bad symptom, but it becomes more dangerous if con- 
vulsions should occur. The same remarks apply to the brain symptoms of renal 
disease. — Ed.'] 



40 GRAVES'S CLINICAL LECTURES. 

alvine discharges. The stimulus of the purgative causes an in- 
creased flow of bile into the intestines, which removes the hepatic 
congestion, and carries off what is popularly termed the dregs of 
the disease, and promotes a rapid and complete recovery. It is a 
simple but successful practice, and I would advise you never to 
omit its employment in cases of this description. 

With respect to purgative mixtures, I may observe that you 
should prescribe a larger quantity of the infusion of senna than is 
generally ordered, if you wish to secure its certain and decided 
operation on the intestines. Hospital nurses, who reason from 
facts and experience, know this, and when directed to give a senna 
draught they always give a small teacupful. Tbe}^ administer 
from four to six ounces at a time, and I have observed that in this 
way the action of the medicine is more certain, and the benefit de- 
rived from it more extensive. I am convinced that the usual mode 
of giving this valuable purgative in private practice is bad ; the 
quantity given is too small, and consequently it is necessary to 
repeat the dose several times, a mode of proceeding apt to occasion 
much nausea and griping : I would therefore recommend a quantity 
varying from three to six ounces, to be administered in all cases 
where the patient's condition will admit of free purging. A most 
accurate observer of the effects of medicines, Mr. Kirby. is in the 
habit of ordering purgative mixtures in chronic cases to be taken at 
bed-time, and not, as is usually done, in the morning. He asserts 
that their action is milder and less irritating to the bowels when 
the patient lies in bed and is asleep until the period of their opera- 
tion, than if he were up and about. 

After the purgative had produced four copious discharges, I pre- 
scribed eight minims of black drop, to be taken at a late hour in 
the evening. Whenever I give opiates to procure sleep, I always 
observe the rule laid down by Dr. M'Bride (a celebrated physician 
of this city), to select the period at which nature usually brings on 
sleep, and which varies according to circumstances and the habits 
of the patient. Whenever you have to deal with watchfulness in 
patients labouring under morbid states of the constitution, as, for 
instance, hectic, inquire when the tendency to sleep usually occurs, 
and administer your narcotic about an hour or two before its occur- 
rence. It is between three and five o'clock in the morning that the 
inclination to sleep is strongest ; it is about this time that sentinels 
are most apt to slumber at their post, and consequently attacks 
upon camps or cities, made with the intention of affecting a sur- 
prise, are usually undertaken about this period of the morning. 
How well marked is the periodic tendency to sleep at this hour in 
all patients labouring under hectic fever produced by whatever 
cause. How often do we hear the poor sufferer complain of rest- 
lessly tossing about in his bed until three or four o'clock in the 
morning, when at last sleep, welcome although uneasy, for a few 
ours separates the patient from his pains. If given at an early 
hour in the evening, the eflect of the opiate is not coincident with 



SLEEPLESSNESS. 41 

this periodic attempt of the constitution, and it fails in producing 
sleep : but if exhibited at a late hour, it begins to produce its sporific 
effect at the very time when nature inclines the harassed sufferer to 
repose, and the result of these combined influences is a deep, tranquil, 
and refreshing sleep. By observing this simple rule, I have often 
succeeded in producing sleep in cases where various narcotics had 
not only failed, but even added considerably to the irritation and 
discomfort of the patient. 

In cases of sleeplessness, where you have administered an opiate 
with effect, be careful to follow it up for some time, and do not rest 
satisfied with having given a momentary check to the current of 
morbid action. To arrest it completely, you must persevere in the 
same plan of treatment for a few days, until the tendency to sleep 
at a fixed hour becomes decidedly established. You must give an 
opiate the next night and the night after, and so on for five or six 
nights in succession; and where the watchfulness has been of an 
obstinate and persistent character, narcotics must be employed for 
a longer period and in undiminished doses. I do not allude here to 
the sleeplessness which accompanies confirmed hectic and other in- 
curable diseases ; such cases require a particular mode of treatment, 
and generally call for all the varied resources of medicine. But in 
those instances of watchfulness, which are frequently observed 
towards the termination of acute diseases, it is always necessary to 
repeat the opiate for some time after you have succeeded in giving 
a check to this symptom. You need not be afraid of giving suc- 
cessive opiates lest the patient should become accustomed to them 
and a bad habit be generated, for the rapid convalescence and re- 
newed health, which are wonderfully promoted by securing a sound 
and refreshing sleep, will soorf enable him to dispense with the use 
of opiates. 

Another disease in which sleeplessness is a prominent symptom, 
is delirium tremens. We have had an example recently in our 
wards, and you have seen the means employed to overcome it. 
The patient came into hospital with symptoms of extreme nerv- 
ous excitement and watchfulness, which had continued for some 
time, and were brought on, as is most commonly the case, by 
repeated fits of intoxication, succeeded by a pause of perfect 
sobriety — in Irishmen the result of necessity or accident. In this 
man you must have remarked the signal benefit which attended 
the use of a combination of tartar emetic and opium, and how 
rapidly the watchfulness disappeared. I shall not enter into the 
details at present, as I purpose to return to this subject on a future 
occasion. 

There is, however, one form of nervous irritability, frequently 
observed in persons who are in the habit of drinking freely, but 
without running into excess, and presenting as it were a shadow 
of delirium tremens, on which I shall make a few remarks. This 
curious stale of the nervous system is generally found to exist in 
men about the middle period of life, and who consume a larger 

4* 



42 GRAVES'S CLINICAL LECTURES. 

quantity of spirituous liquors than they are able to bear. Such 
persons, without suffering in appearance, or losing flesh, get into a 
chronic state of disturbed health, manifested by nausea, and even 
dry retching in the morning, loss of appetite, and impaired diges- 
tion ; but in particular by a deranged and irritable state of the 
nervous system, and by watchfulness. This forms one of the most 
distressing symptoms, and the patient generally complains that he 
cannot get any sound and refreshing sleep, that he lays awake for 
hours together, and that when he slumbers his rest is disturbed by 
disagreeable dreams, or broken by slight noises. How are you to 
treat this affection ? I can give you a valuable remedy for this 
deranged state of constitution — one which I have often tried, and 
which, from experience, I can strongly recommend. It is a mix- 
ture composed of tincture of columbo, quassia, gentian, and bark — 
say an ounce of each ; and to this is added a grain, or even two, of 
morphia. A compound tincture, somewhat analogous to this, is 
much in use among military gentlemen, and others, who have 
resided for a considerable time in India, where, from the heat of 
the climate, and the prevalence of intemperate habits, the stomach 
becomes relaxed and the nervous system irritable, so as to repre- 
sent, in a minor degree, the symptoms which characterise delirium 
tremens. You perceive I combine several tonics to form this mix- 
ture, because they are well known to produce a more beneficial 
effect when combined than when administered singly ; and I add 
to these a narcotic, which has the property of allaying nervous 
excitement without derangement of the intestinal canal. The dose 
of this mixture is a teaspoonful three or four times a day, and the 
best time for taking it is about an hour before meals. It gradually 
removes the nausea and debility of»stomach, lessens nervous irri- 
tability and watchfulness, and with a proper and well regulated diet, 
and attention to the state of the bowels, I have seen it produce 
excellent effects. In such persons much benefit is derived from 
the use of the tepid shower-bath. 

Fever is another disease in which sleeplessness is a symptom, 
frequently of an unmanageable character, and pregnant with dan- 
ger to the patient. You witnessed this in the case of the boy who 
lies in the small Fever Ward, next to the man who is at present 
labouring under general arthritis. This boy had fever of a mild 
description, and unattended with any bad symptoms. His case 
scarcely required any attention, and he had almost arrived at a 
state of convalescence without the aid of medicine, when he began 
to lose his rest, and absolutely became sleepless for several nights. 
I beg your attention to this case, for many reasons. In the first 
place, you have seen that we tried many remedies without success, 
and afterwards fortunately hit on one which answered our purpose 
completely. Let us examine the nature of the medicines prescribed, 
and our reasons for giving them. 

In the first place we gave, as in the case of jaundice, an aperient, 
followed by a full dose of black drop. It failed in producing any 



SLEEPLESSNESS. 43 

sleep ; we repeated it a second and a third time, but without the 
slightest benefit. I then remarked to the class, that, as I had 
noticed the good effects resulting from a combination of tartar 
emetic and opium in the case of delirium tremens, where opium 
alone failed in procuring sleep, it would be proper to give this 
remedy a trial. I observed, at the same time, that I was convinced 
that the preparations of antimony have a distinct narcotic effect, 
and that I had seen patients in fever whose watchfulness had been 
removed by antimony given in the form of tartar emetic or James's 
powder. I said it was my firm impression that tartar emetic, along 
with its other effects, exerts a decided narcotic influence on the 
system, and that it is this which makes it so valuable a remedy in 
treating the sleeplessness of fever and delirium tremens. Hence 
I have been in the habit of giving tartar emetic combined with 
opium, in fever, and, I must add, with very great success. Our 
predecessors were much in the habit of using antimonial mixtures 
in the treatment of fever; and they did this because they knew, by 
experience, that these remedies worked well. It is at present too 
much the fashion to decry their practice, and in this instance, I 
think, with very little justice. 

In this boy's case, however, the combination of tartar emetic and 
opium did not succeed in producing sleep. Having thus failed in 
our first and second attempts, we had recourse to the liquor muri- 
atis morphise — a preparation first brought into use by Dr. Chris- 
tison, and which, in the form usually employed, is equal in strength 
to laudanum. It is an exceedingly valuable preparation for many 
reasons, and one which has the strongest claims to your notice. 
Being of the same strength as laudanum, it saves the trouble of 
learning and remembering new doses, and, in addition to this, it 
possesses the more important advantages of inducing sleep with 
more certainty, and not acting as an astringent on the bowels, or 
affecting the head so frequently as laudanum. You observe that I 
say so frequently ; I do so because cases now and then occur in 
which even moderate doses of the liquor of the muriate of mor- 
phia produce quite as much headache as laudanum. I prescribed 
the former in doses of fifteen drops every six hours, so as to give 
sixty drops in the day, and continued this practice for two days, but 
without the slightest effect. Here you see three modes of inducing 
sleep completely failed. The boy remained for a day without 
taking any medicine, and then we made another attempt, which 
was more successful. We first prescribed a purgative enema, and 
after this had operated he was ordered an opiate injection, consist- 
ing of four ounces of mucilage of starch and half a dram of laud- 
anum. He fell asleep shortly after using the opiate injection, and 
did not awake until the next morning. The following night the 
opiate was repeated in the same form, and with equal success ; 
convalescence went on rapidly, and the boy's health is now quite 
re-established. 

Here, then, is a singular fact attested by this case, that opiates in 



44 GRAVES'S CLINICAL LECTURES. 

the form of injection will succeed in producing sleep, where they 
have connpletely failed when administered even in large and re- 
peated doses by the mouth. Baron Dupuytren was the first who 
made this important observation, and proved that narcotics applied 
to the mucous surface of the rectum exercise a powerful influence 
on the nervous system, always equal, and very often superior, to 
the effect produced by taking them into the stomach. He maintains 
that, in delirium traumaticum and delirium tremens, a certain quan- 
tity of opium, when prescribed in the form of enema, will act with 
more decided effect in allaying nervous excitement than the same, 
or even a larger quantity, when taken by the mouth. I have no 
hesitation in giving full credit to this assertion, as the results of my 
experience tend strongly to confirm its truth. I have, not long 
since, published, in the Dublin Med. Journal, the case of a patient 
in Sir P. Dun's Hospital, who was reduced to the last stage of debi- 
lity and emaciation from the combined efl?ects of mercury and 
syphihs. The torture which this man endured from nocturnal 
pains, and a total deprivation of sleep, was such that he swallowed 
enormous doses of opium ; in fact, he had, previously to his admis- 
sion into Sir P. Dun's Hospital, exhausted all his means in pur- 
chasing opium. While in hospital, he used to take 150 drops of 
black drop in the course of a day, and yet, notwithstanding these 
excessive doses, he could only get a few minutes of unrefreshing 
slumber. After some time I changed the plan of treatment, and 
had the black drop administered in the form of enema. It suc- 
ceeded in producing a decided soporific effect, and in a short time 
he was able to enjoy a sufficient quantity of repose, from taking 
only one tenth of the quantity used by the mouth. I have also, in 
the same paper, adverted to the case of a medical gentleman who 
laboured under an affection of his joints, which was accompanied 
hy spasms of the limbs and most excruciating pains. His agony 
was so intense that he used to swallow grain after grain of opium, 
until he had taken to the amount of thirty or forty grains, with 
the view of procuring some alleviation of his sufferings. He was 
prevailed on to give up altogether the use of opium by the mouth, 
and employ it in the form of enema, which he did with the most 
striking advantage — the quantity which succeeded in giving rehef 
in this way being scarcely the twentienth part of what he ordinarily 
used. 

It is unnecessary for me to enter here into any discussion with 
respect to the nature and treatment of delirium traumaticum, and 
the sleeplessness which always accompanies it, as you w^ill find 
this subject very ably treated in M. Dupuytren's works, and in a 
very instructive and elegant lecture delivered by Mr. Crampton 
(the surgeon-general) in this hospital, and published in the last 
volume of the London Medical and Surgical Journal. There is, 
however, one kind of sleeplessness, arising from irritation of the 
skin produced by blisters, which frequently assumes a very serious 
character, and on which it may be necessary to oflfer a few observ- 



SLEEPLESSNESS. 45 

ations, as the subject has not been noticed sufficiently by practical 
writers. Trifling as the irritation resulting from a blister may seem, 
yet, under certain circumstances, it is a symptom of highly dan- 
gerous aspect, and becomes a source of just alarm. I have wit- 
nessed the loss of some lives from this cause, and many patients 
have, to my knowledge, been rescued from impending danger, by 
an early and proper share of attention being directed to its pheno- 
mena and treatment. 

The bad effects on the nervous system, occasionally produced by 
the application of blisters, are somewhat analogous to those which 
result from wounds and other external injuries, and to be accounted 
for on the same principle. Wounds and injuries sometimes make 
an impression on the nervous system, by no means proportioned to 
the importance of the injured organ to life, or to the extent of the 
mischief. An injury, produced by a body which strikes the sen- 
tient extremities of the nerves with great force, will sometimes pro- 
duce very remarkable effects on the system. Thus, a musket-ball 
striking a limb may, without wounding any great artery or nerve, 
or destroying any part of importance to life, produce a train of 
nervous symptoms of an extraordinary character. The person, 
without feeling much pain, and scarcely knowing that he has been 
wounded, without being terrified or having his imagination excited 
by any apprehended dangers, turns pale, gets a tendency to faint, 
and sometimes actually dies from the impression made on the nerv- 
ous system. In the same way an external injury reacting on the 
nerves may bring on high mental excitement, delirium, and a total 
privation of sleep, as we exemplified in delirium traumaticum. I 
mention this with the view of establishing the proposition, that 
impressions made on the sentient extremities of the nerves are 
sometimes reflected on the nervous centres, producing the most 
alarming effects. In this way we can understand how the irritation 
of blisters may produce sleeplessness, m.ental aberration, and a train 
of symptoms analogous to those which characterise delirium trau- 
maticum. 

The delirium and sleeplessness arising from the irritation of 
blisters is by no means an uncommon disease. I have seen many 
examples of it in private practice, and lam anxious that you should 
be acquainted with its nature and treatment. It is generally met 
with in the case of children, in whom the cutaneous surface is 
extremely tender and irritable. I could relate several instances in 
which I have been called on to visit children labouring under 
fever, where symptoms of high nervous excitement were present, 
and where I found the little patients delirious, screaming, and per- 
fectly sleepless from this cause. I have found this alarming affec- 
tion generally occurring at an advanced stage of fever, and exhibit- 
ing a train of sym.ptoms which closely resemble hydrocephalus. I 
have observed that after the application of a blister to relieve some 
suspected cerebral or abdominal or thoracic affection, jactitation, 
restlessness, constant application of the hand to the head, and deli- 



46 GRAVES'S CLINICAL LECTURES. 

rium have appeared, and that these symptoms had been mistaken 
for incipient cerebritis or hydrocephalus, and treated with leeches 
and purgatives. When the blister has been applied to the nape of 
the neck, the soreness and irritation of the skin on that part cause 
the child to roll its head from side to side on the pillow, icith that 
peculiar motion and scream supposed to prove to a demonstration 
the existence of hydrocephalus. I have learned also, that the above 
measures, so far from giving relief, have only tended to produce an 
exacerbation of the disease, and that the medical attendant has 
given up the case in despair. Now, gentlemen, if called to such a 
case what should be your practice ? In four cases of this kind I 
gave my opinion frankly to the medical attendant, and told him he 
was pursuing a wrong course, that the disease was analogous to 
delirium traumaticum, and not to be treated by leeches or purga- 
tives, and least of all by blisters. I observed to him that these 
symptoms had made their appearance shortly after the child had 
been blistered for suspected disease of the belly, or head, or chest ; 
and that it was useless to attempt to remove the disease by leeches, 
or purgatives, or blisters. The remedy I always proposed was 
opium, and it was acknowledged in four or five cases, that this 
remedy had succeeded not merely in relieving the existing symp- 
toms, put in saving the patient's life. In such cases, particularly 
in young children, the opium must be given in small but frequently 
repeated doses, so as to ensure its energetic but safe action, and the 
greatest care must be taken to soothe the irritated portion of the 
skin by ointments, poultices, etc., while unwearied diligence must 
be bestowed upon the task of preventing the child from scratching 
the blistered surface. To effect this the child's hands must be 
muffled in appropriate gloves, and must be secured in the sleeves 
of a shirt made for the purpose. 

I beg your attention still further to this subject of sleeplessness 
and delirium. I wish to mention the case of a gentleman who was 
a pupil of mine. This gentleman studied hard, attended lectures 
regularly, and was constantly in the dissecting room. While thus 
occupied, he happened to wound one of his toes in paring a corn, 
and afterwards wore a tight shoe on the injured foot. A small 
imperfect abscess formed in the situation of the corn, which was 
opened by one of his fellow-students ; the incision gave very great 
pain, and was not followed by any discharge of matter. Next day 
he was feverish, and the lymphatics of the injured limb became 
extensively engaged, the inflammation ascending towards the 
glands of the groin and having a tendency to form a chain of 
insulated patches in different parts of the leg and thigh along the 
course of the lymphatics. This you will generally find to be the 
case in inflammatory affections of the lymphatics ; the inflamma- 
tion is seldom continuous, but, in the majority of cases, is developed 
at certain insulated points, where small difluse suppurations form 
very rapidly. After a few days, this young gentleman's fever 
increased to an alarming height, he became completely sleepless, 



SLEEPLESSNESS. 47 

and had incessant delirium. He was purged briskly, leeched ex- 
tensively and repeatedly, his head shaved, and cold applications so 
constantly applied, that he appeared half drowned and collapsed. 
Notwithstanding this very active treatment not the slightest relief 
was obtained ; neither were the symptoms mitigated by incisions 
made in the inflamed patches for the purpose of evacuating matter; 
the sleeplessness continued, and the delirium was as wild as ever. 
I saw him on the seventh or eighth day, when all antiphlogistic 
measures had failed, and his friends were quite in despair. On 
being asked my opinion, I stated that I looked upon the case as 
one of delirium, not proceeding from any determination to the head 
or inflammation of the brain, but depending on a cause analogous to 
those which produced delirium traumaticum, and that instead of 
antiphlogistics I would recommend a large dose of opium and some 
porter to be immediately given. Mr. Cusack, who visited the 
patient after me, concurred in this view, and a full opiate was 
administered in repeated doses. It succeeded in producing sleep 
and tranquilising the nervous excitement. 1 may here observe 
that a few days afterwards this gentleman had a return of the 
symptoms of cerebral disturbance with sleeplessness, in conse- 
quence of omitting his opiate, and that the opiate and porter were 
again administered, and again succeeded in removing the delirium 
and watchfulness. By perseverance in the use of the same means, 
the disease was completely removed, and convalescence established. 
The last kind of sleeplessness to which I shall direct your atten- 
tion, is that which is frequently met with in persons of a nervous 
and irritable disposition, in hypochondriacs and hysterical females. 
You will find such persons, although of active habits and with 
tolerable appetites, complaining of a total privation of their natural 
resi, and it is astonishing to think how long they may continue 
subject to this harassing watchfulness. I have frequently observed 
this aflfection among females of nervous habit, who possessed strong 
feelings of attachment to the interest and welfare of their families, 
and who were remarkable for an exemplary and over anxious dis- 
charge of their domestic duties. It is also very often met with in 
the upper classes of life, where the susceptibility to nervous excite- 
ment is morbidly increased by fashionable habits. I shall not enter 
into the various moral causes which tend to produce this state of 
the nervous system, and will content myself for the present with 
giving you some hints for the treatment of this obscure affection. 
As yet I have not any distinct and accurate notions of the disease, 
and can only guess at the treatment ; but this much I may state, that 
such cases are not to be cured by the means which I have already 
detailed. If they are to be cured by any means, I think it is by 
antispasmodics, and remedies which have a gentle stimulant, and, 
if I may so express myself, alterative effect on the nervous system. 
I have cured two cases of this kind by musk and assafcetida, where 
every other remedy had failed. To one of these I was called by 
my friend, Dr. Neason Adams ; the patient was a lady of delicate 



48 GRAVES'S CLINICAL LECTURES. 

constitution and hysterical habit ; she was emaciated, and suffered 
from a total loss of rest, but had no other disease. All kinds of 
narcotics had been tried unsuccessfully, and opium in all its forms 
had failed in procuring sleep. I advised the use of musk in doses 
of a grain every second hour, and this means proved eminently 
successful. In another case I succeeded by administering the same 
remedy in combination with assafoetida. I have also remarked 
that assafoetida alone, given in doses of two or three grains three 
times a day, has very considerable effect in calming nervous irrita- 
tion of this description, and restoring the patient to the enjoyment 
of more prolonged and refreshing sleep. In all such cases the phy- 
sician must be most careful to have the appearance of not thinking 
the loss of sleep as a matter of much consequence, and the family of 
the patient must be directed to speak as little about the matter in 
his presence as possible ; — nay, so powerful is the operation of 
moral impressions, that in one case, which I attended along with 
Mr. Halahan, I succeeded in procuring sleep by ordering a musk 
pill to be given every second hour night and day, and by desiring 
the patient to be awakened, should she be asleep, at the time the 
pill was to be taken. I laid great stress on the importance of so 
proceeding, and thereby produced so strong an effect on the patient's 
mind, and inspired so great a confidence in the efficacy of the medi- 
cine, that she went to bed, not so much afraid of lying awake as 
afraid of being asleep at the hours when she ought to take a pill. 
The idea which had hitherto fixedly occupied her mind was dis- 
placed by a new impression, and relief was obtained the very first 
night. 

In affections of the head occurring in acute diseases, and attended 
with raving and loss of rest, it is a very usual practice to direct the 
application of cold lotions to the shaved scalp. 

Permit me, gentlemen, to make a few remarks upon this im- 
portant subject. I wish I could make myself well understood on 
this point, for I have seldom met with any person who seemed 
to bear in mind the true principle upon which cold is applied 
as a means of repressing local heat. In cases of determination 
of blood to the head occurring in fever, the common practice 
is to have the head shaved and cold lotions applied. Enter the 
room of a patient who is using cold applications, and you will 
observe the process conducted with great apparent nicety ; the 
head is accurately shaved and carefully observed with folds of linen 
wet with a lotion to which spirit of rosemary or some odoriferous 
tincture has communicated an agreeable and refreshing smell; but 
when you come to examine the patient, you find his head smoking 
and the heat of his scalp increased. The nurse applies the lotion 
once every half hour, or perhaps not so often ; indeed, she seldom 
repeats the application until her notice is attracted by the steam 
rising from the patient's head, or until she herself, awaking from a 
comfortable sleep, and going over to examine the state of the 
patient's head, find the folds of linen which cover it as hot and 



SLEEPLESSNESS. 49 

dry as if they had been hung before a fire. Whether applied to 
reduce local inflammation in any part of the body, or to cool the 
scalp in determination to the head, cold lotions as ordinarily em- 
ployed do infinitely more harm than good. The cold is applied 
at distant intervals, its effect soon ceases, and reaction constantly 
takes place, leaving the part as hot or even hotter than it was 
before. 

If you put your hand into snow for a few moments and then take 
it out, it quickly resumes its natural heat ; and if you repeat this 
at considerable intervals, so as to give time for reaction to occur, 
the vessels assume a more energetic action, and it becomes hot and 
burning. If you continue to keep it in the snow for a long time, 
its heat becomes completely exhausted, reaction does not take 
place until after a considerable period, and very slowly, and the 
hand remains at a very low temperature for a good while. Bear 
this in mind, for it will direct you in the application of cold to 
reduce local heat. If cold applications be used at such intervals 
as to allow the scalp to react and resume its heat, rely upon it, it is 
much better to forbid them altogether. Where you wish to apply 
cold with effect, let it be done by relays of folded linen, wet with 
any frigorific mixture, and repeatedly applied to the scalp so as to 
leave no smoking, or, what is much better, get three or four blad- 
ders, put into each a quantity of pounded ice, and apply one over 
the crown of the head, one on each side, and lay one on the pillow 
for the back of the head to rest on. 

There is a vast difference between a thing being done and its 
being well done: so it is with regard to cold lotions; so difficult is 
it to insure their proper application, that I have entirely given them 
up in hospital practice, and rarely order them in private. I have 
been induced to abandon them in consequence of witnessing so 
many instances in which my directions were neglected, and con- 
sequently the cerebral congestion was augmented by their mal- 
application. Another serious inconvenience frequently arises from 
their use when applied in a slovenly manner, which is the danger 
of cold arising from the pillow and bed-clothes being wetted. 

It is a curious fact that the head is the only one of the three 
cavities with respect to which long established custom has laid 
down the maxim, that when its contents are inflamed we may cool 
the surface over it, while in inflammatory affections of the thoracic 
or abdominal viscera this practice is avoided as dangerous and 
inapplicable. Latterly, however, some medical men have been 
inclined to question the grounds on which cold applications have 
been rejected in the two latter cases, and some have even declared 
that they have used ice poultices in inflammations of the chest and 
belly with great success and perfect safety.* I. am not as yet pre- 

* [In gastritis of a violent character, with intense heat and frequent vomiting-, 
this is a most excellent practice, and fully borne out by oar own experience ; nor 
have we ever seen any inconvenience result from it. A bladder of ice may be 
applied over the epigastrium and removed as soon as it melts, but if the skin 

5 



50 GRAVES'S CLIJNICAL LECTURES. 

pared to adopt this practice, although I must confess that a review 
of the subject might incline me to give up my prejudices on this 
point. It is certainly but reasonable to think that what is true of 
the one may be also true of the other, and that the application of 
cold to the head and heat to the chest and belly has nothing in its 
favour beyond mere custom. It should be recollected, however, 
that the head and face are more accustomed to cold than the chest 
and belly, and hence are less liable to any mischief likely to arise 
from its application in an intense degree. Still I am inclined to 
think that there is much prejudice connected with the practice of 
applying cold to the head ; and I have very little doubt that if the 
matter was properly investigated, and a number of experiments 
made, it would lead to the abandonment of cold applications in most 
inflammatory diseases of the brain. In fevers, I can say positively 
that in the majority of cases they are positively injurious, as usually 
applied; sponging the bare scalp with tepid or warm vinegar and 
water, or even frequently repeated sleeping of the head and tem- 
ples, will often succeed much better in abating the headache and 
restlessness of fever than any cold applications whatsoever. In 
1832, a violent influenza, accompanied by most distressing head- 
ache, attacked thousands in Dublin ; this intense pain in the head 
was relieved by nothing so etTectually as by diligent steeping of the 
temples, forehead, occiput, and nape of the neck, with water as hot 
as could be home. 

I do not speak here of the application of cold to the head for the 
purpose of relieving local heat and inflammation, but to produce an 
eflfect on the whole system. Cold thus applied is of decided and 
unequivocal value. You are aware that in cases of fever accom- 
panied by symptoms of high mental excitement and great heat of 
skin, the use of cold dashing has produced the most extraordinary 
eflfects. Again, if a patient has taken too large a dose of prussic 
acid or any other narcotic, the best mode of rousing him is by pour- 
ing water on his face or chest from a height. In Turkey, if a person 
happens to fall asleep in the neighbourhood of a poppy-field, and 
the wind blows over it towards him, he becomes gradually nar- 
cotised, and w^ould die, if the country-people, who are well ac- 
quainted with this circumstance, did not bring him to the next well 
or stream, and empty pitcher after pitcher on his face arvd body. 
This occurred to my friend. Dr. Oppenheim, during his residence in 
Turkey, and he owes his life to this simple but efl^ectual treatment. 

To conclude, gentlemen, I may observe that sleeplessness in a 
chronic form is often produced by dyspepsia, and can only be 
relieved by the means suited to indigestion. Here it is that small 

should become cool, or the patient chill}^ it should be immediately laid aside. 
In sub-acute cases we have never seen the remedy employed, nor do "we think 
advisable unless in rare exceptional cases. We have not resorted to cold appli- 
cations in thoracic inflammations, because the sensation of heat and burning is 
rarely felt, and the patient is much more soothed by warm applications than in 
inflammations of the abdominal viscera. — Ed.'\ 



GANGRENE AND PLEURITIS. 51 

doses of .blue pill and tonic purgatives are of infinite service, com- 
bined with change of air, of scene, and an appropriate diet. In 
many females, sleeplessness is combined with menstrual irregularity, 
and can only be cured by means calculated to invigorate the health 
and restore (he catamenial discharge to its natural periods and 
quantity, for the nervous system suffers equally whether they be 
suppressed or over abundant. It is singular how long sleeplessness 
often continues in chlorosis without inducing those serious conse- 
quences that are produced by this symptom in other morbid states 
of the system. In such cases much is sometimes accomplished by 
means of the common preparations of morphia, or by the use of 
Hoffman's liquor (liquor aslhereus oleosus), camphor, and other 
medicines that act upon the nervous system. It must be confessed, 
however, that these and every other expedient to obtain sleep often 
fail in chlorotic and hysterical females, in whom relief is only 
obtained by a gradual improvement of the general health and men- 
strual function. 



LECTURE IV. 

GANGRENE AND PLEURITIS. 

I HAVE here the lungs of a patient who died yesterday in the 
fever ward, and to whose case I have frequently directed your at- 
tention. They present some pathological phenomena of consider- 
able interest, and I would advise you to examine them carefully 
after lectin'e. 

The patient, who w^as advanced in life and of a feeble constitu- 
tion, had been ill for a week before his admission, with symptoms 
of dyspnoea, cough, and pain in the left side, which appeared 
shortly after his recovery from an attack of fever. On examining 
him the morning after his admission, we found the interior part of 
the left lung dull on percussion, the dulness extending much 
higher up posteriorly and anteriorly. On applying the stetho- 
scope, we observed that, over a space about the size of two palms, 
no sound, morbid or otherwise, could be heard ; but above the line 
which bounded this space there were crepitating rales and bronchial 
respiration. We had, therefore, a twofold affection of the lung, 
pleuritis, as indicated by the pain in the side, dulness on percussion, 
and absence of all sound over a certain portion of the chest ; and 
pneumonia, as indicated by cough and expectoration of viscid 
sputa, tinged with blood, dulness of sound on percussion, bronchial 
respiration, and crepitating rales. It is unnecessary for me to reca- 
pitulate all his symptoms, as I have, while visiting the wards, 
mentioned them in detail, and I shall merely state, that our exami- 
nation showed that this man, in the first place, was labouring under 



52 GRAVES'S CLINICAL LECTURES. 

pleuritis, and that it was of that kind which is called dry pleurisy, 
and where there is no tendency to considerable effusion ; and, in 
the next place, that he had pneumonia of the inferior lobe of the 
left lung, extending up into the middle lobe posteriorly. You will 
recollect that, at the lime of our examination, I marked on his skin 
with a pen the extent of the pleuritic inflammation as well as of 
the pneumonia, and you will find, by examining this lung, that my 
diagnosis was correct. You will observe the pleura presenting, 
over its inferior part, laterally and posteriorly, an effusion of lymph, 
with a very small quantity of sero-purulent fluid; and here is the 
seat of the pneumonia, which occupied precisely the portion I 
pointed out and no more. 

With respect to treatment, it was antiphlogistic, pushed as far as 
the advanced stage of the disease and the age and debility of the 
patient permitted. He was leeched and blistered, and this was im- 
mediately followed up by the use of calomel and opium, and the 
application of mercurial ointment over the affected portion of the 
chest. This treatment appeared to check the disease and stop the 
progress of disorganisation in the lung ; at least it certainly arrested 
the pleuritis. The pulse became more tranquil, and what encou- 
raged us to entertain some slight hopes was, that the difficulty of 
breathing subsided, and respiration became less frequent, although 
it was never reduced to anything like a natural standard. I have 
already told you, that in studying acute and chronic affections of 
the chest, the two chief symptoms to be attended to, are the num- 
ber of respirations which occur in a minute, and the amount of 
dyspnoea complained of by the patient. Here, though the respira- 
tions sank from forty to thirty, still they were nearly double the 
natural frequency; and this, coupled with the age and debility of 
the patient, forbade us to hope for a cure. Though the pulse had 
become more tranquil, and the bloody expectoration had ceased, 
though dyspnoea was no longer complained of, and the frequency 
of respiration had become reduced, still the man's countenance ex- 
hibited strong marks of suffering and debility, and the stethoscope 
showed that the disease still continued, and there was no tendency 
to resolution in the affected lung. Here the stethoscope was of 
great value. A person ignorant of its use, observing the tranquil 
state of the pulse, the diminution in the frequency of respiration 
and the cessation of dyspnoea, might be led to believe that the man 
was getting better, and to pronounce that the period of convales- 
cence was near. But the stethoscope told us that the hepatisation 
of the lung had no tendency to resolution, and when we observed, 
after a week, that it was still undiminished in extent, we were led 
to form an unfavourable prognosis. VVe knew that matters could 
not remain long in this state ; we knew that the disorganised lung 
acted as an irritant tending to keep up disease, and that the man 
was every moment liable to a fresh attack of inflammation. 

In the mean time the patient caught a fresh cold, from being 
exposed to the thorough air of our too well ventilated wards. This 



GANGRENE AND PLEURITIS. 53 

fell on his larynx, producing hoarseness, stridulous breathing, and 
copious expectoration. When an old person, reduced by some 
previous disease, catches cold, and gets, in consequence, a sudden 
and remarkable hoarseness, so that he can only speak in whispers: 
when, in addition to this, he has cough, stridulous breathing, and 
copious muco-purulent expectoration, you may be sure that the 
case is a bad one, and the patient in most imminent danger. In- 
flammation of the larynx in children is, you all know, a violent 
disease, it terminates in an effusion of lymph which, if not pre- 
vented, or remedied, by the most prompt and decided measures, too 
often produces fatal obstruction to the entrance of air, and death 
from asphyxia. In the adult, laryngitis does not, except in a very 
few instances, cause an efflision of lymph ; still it is a severe disease, 
and well calculated to excite alarm. In the aged it is accompanied 
by considerable fever, and, what you would suppose likely to give 
relief, copious expectoration, evidently derived from the larynx 
itself; and yet I do not recollect that I have ever seen a case of 
this kind that did not terminate fatally. I have very recently 
visited a case of this description, which occurred in the person of 
an eminent country practitioner, who had just come up to Dublin. 
He got an attack of cold, followed by hoarseness, which went, on 
for two or three days without being attended to, until one evening 
he suddenly became alarmingly ill, and was obliged to send for 
his friend. Dr. Evanson, who prescribed and called on me the next 
day. I found him labouring under stridulous breathing, constant 
laryngeal cough, prostration of strength, and enormous muco- 
purulent expectoration. His pulse was very rapid, he complained 
much of oppression of the chest, and died the following night, more 
with symptoms of exhaustion than of asphyxia. 

The symptoms of laryngitis, which arose thus suddenly in our 
patient, were quickly succeeded by others. On Saturday morning 
we found him much worse, his countenance was sunk and livid, 
and his breath had become extremely fetid. His expectoration also 
exhibited a very remarkable change; it was greenish, ichorous, and 
had a most intolerable fetor. He now began to manifest symptoms 
of awful prostration, his distress of respiration became intense, his 
eyes fixed, his extremities cold, and he expired in about forty hours 
from the commencement of the attack. 

Here, gentlemen, a man, after fever, gets an attack of pleuro- 
pneumonia, this is relieved to a certain extent by treatment, but the 
hepatisalion remains unresolved. At the end of three weeks he 
gets an attack of laryngitis ; in addition to this, gangrene seizes on 
the diseased lung, and he sinks with great rapidity. Where gan- 
grene attacks the limbs it may creep on slowly, and life may be 
prolonged for a considerable time, but when it fixes on internal 
organs its course is rapid, and generally proves fatal in a few da>^s. 
In the lung, unless the patient's constitution is unimpaired and the 
disease limited, it will terminate quickly in death, and you have 
seen that, in this case, it only lasted from Saturdav until* Monday 

6* 



54 GRAVES'S CLINICAL LECTURES. 

morning, that is to say about forty hours. Alter the acnte stage 
of pneumonia had passed away, as deuoted b j the aleence of fever 
and bloody sputa, and diminution of dyspncea, and freqneDcy of 
respiration, the case assumes a chronic character, which contmoK 
for nearly a fortnight, and then a new order of sjmptcMiis aj^iears, 
manifested by fetid breath and expectoration, soddeo piostratioo of 
strength, Hippocratic face, and coid extremities. These who have 
watched this case must have been struck with theselhree remade- 
able stages : the £rst stage of iQ^ammaiioOy the succeeding one of 
chronic disease, and the termination in gan^rencL It is not osoal 
to find gangrene of the lung superrenii^ on inflammation which 
is arrived at the chronic stage ; it is most conunonlj the residt irf 
acote inflammation of inieose character, and ccMnes cm at a Teiy 
eaiiy period of the disease. 

How we are to account for this sudden s up e rve ntionof gangrene I 
There was nothing in the oatore of the pneomcmic inflammation 
to dispose it to terminate in this way. It had lasted for three weeks, 
and had arrived at a stage ia which inflammation Tcry rardj 
assumes the gangrenous character. To what, then, are we to attri- 
bute it ? Partly to the debility of the man's constitution, and parti j 
to an erysipelatous tendency in the air^ which is now very pieralent. 
Except there was something to dispose the lung to gangrenous 
disease, as an enfeebled habit and a vitiated ^piality of atmosphere, 
we could not, under the existing circom^ances, have expected such 
a termination. That this view of the subject is correct, is shown 
by the simultaneous occurrence of gangrene in another part, which 
had not been previously diseased, or subject to infiammation, except 
shorth- before the man's death, — I allude to the laiynx. If you 
.examine the larynx you will find the mucoie membrane at the pos- 
terior surface, and where it inv^^ts the chordse vocales, destroyed 
by gangrenous sloughing. You perceiv^e, then, we had gangrene 
io the larynx and lung, simultaneously^ The gangrene of the Im^ 
was not therefore attributable to the occurrence of local inflamma- 
tion having a tendency to gangrene, bat dependent upon a consti- 
tutional affection produced by debility and a vitiated state of atmo- 
sphere. If this man had chanced to get a wound on any part of his 
body, I have no doubt but that it wogM exhibit a gangrenoiK cha- 
racter, and, in the same way, if he happened to get inflammation €€ 
the bowels, it is most probable that this also would have ended in 
gangrene. I have frequeiit33% in the advanced stage of fever, where 
the patient is much reduced, and wi*ere signs of a morbid cfmdition 
of the fluids are present, seen gangrene occur simidtaneoosly in 
various parts of the body. What I wish to impr^ on you is, that 
though the inflammation of the lung ended suddenly in gai^:rene,it 
was not in consequence of ihe inflammation havii^ in itself any 
such tendency, but in consequence of a change produced in the 
man"'s constitution by atmospheric influence, and which was fa- 
voured by his advanced age and great debUiiy. 

The itiference to be drawn from the sodden occurrence of gan- 



GANGRENE AND PLEURITIS. 55 

grene in this case is, that it does not depend merely on violence of 
inflammation. At one time pathologists were inclined to believe 
that gangrene was invariably the result of excessive inflammation, 
or at least of inflammatory action disproportioned to the vitality of 
the parts attacked, and that it was possible to prevent any inflam- 
mation from ending in gangrene by prompt and active treatment. 
But there are certain states of the constitution which have a ten- 
dency to convert every form of inflammation into gangrene, and 
that wholly independent of the violence of the local inflammatory 
action. Thus, a person reduced by fever, small-pox, or malignant 
scarlatina, becomes liable to be attacked with gangrene in various 
parts of the body from the slightest causes. In all parts which are 
exposed to any degree of pressure, you will, under such circum- 
stances, have gangrenous sores formed ; and, even in parts where 
no degree of pressure has been exercised, sphacelus is not unfre- 
quently produced, as we see in many cases of confluent small-pox, 
and in the mortification of the pudenda in female children, which 
sometimes occurs in bad measles. In such instances, gangrene is 
not preceded by symptoms of inflammatory action; and, in the 
present case, it is very probable that no inflammation of the lung, 
properly so called, preceded the gangrenous affection which termi- 
nated life. 

Permit me now to direct your attention to the case of a man 
named T. Kelly, who lies in the upper fever ward, and has been 
under the care of Mr. Knott. He is at present labouring under an 
attack of pleuritis and pneumonia, each modifying the other — the 
pleuritis being here also of that nature which is, by contra-distinc- 
tion, termed dry. A few particulars in this case demand our notice. 
In the first place, from looking at this man and examining his pulse, 
you would never suppose that he was labouring under a formidable 
disease. A careless observer, finding the pulse to be soft, regular, 
and only seventy-two in a minute — that respiration was tolerably 
free, and the skin cool — might here very easily overlook the true 
nature of the disease, and say this man has no fever, no inflamma- 
tion of any internal organ. Yet a careful examination shows that 
the right lung and pleura are extensively engaged. In the next 
place, we find that the pleuro-pneumonia has attacked the upper 
part of the lung instead of the lower. Pneumonia has a great ten- 
dency to attack the lower and posterior parts of the lung ; indeed, 
so frequently do we meet it in this situation, that we look upon its 
occurrence in the upper part of the lung as a rare exception to a 
general rule. The third point connected with this case is, that, 
though the patient is labouring under pleuritis and pneumonia, his 
blood does not exhibit the slightest symptom of being affected by 
this combination of violent inflammations. When drawn from the 
arm, it separated very imperfectly into crassamentum and serum, 
and there was no deposition of that buffy coat which has been so 
often noticed by our ancestors as occurring in pleuritis, and hence 
termed crusta pleuritica. Here, from observing that there was no 



56 GRAVES'S CLINICAL LECTURES. 

formation of coagulum — no cupped or buffed appearance in the 
blood, and that the pulse was soft and regular — some persons would 
have argued that no inflammation was present ; but how false and 
dangerous such a conclusion would be, anyone may convince him- 
self by making a careful stethoscopic examination. The fourth 
point (which was first observed by Mr. Knott) is, that there is a 
considerable disproportion in the size of the sides of the chest ; the 
right side measurinsr better than two inches and a half more than 
the left. Xow, there must be some cause for this : and as the man 
has pleuritis on this side, it would be natural to infer that there is a 
considerable effusion of fluid in the cavity of the pleura, and that 
the dilatation of the side is produced by empyema. There are 
some circumstances, however, in this case which forbid us to adopt 
such a conclusion. In the first place, this great increase of size in 
one side of the chest would indicate a very considerable effusion. 
Ey empyema, I do not mean the effusion of a quantity of lymph, 
which does not push back the lung more than a line, but an effu- 
sion of fluids of various densities, and in large quantity, exercising 
very considerable pressure on the lung, and pushing it back towards 
its root. There are two circumstances in this case "which should 
be attended to : first, the man is a labourer, and in such persons 
the chest, measured across the pectoral muscles, is always found to 
be on the right side half an inch, and sometimes nearly an inch, 
larger than it is on the left. This is accounted for by the increased 
development of the muscles of the right side from constant use. 
In the next place, we find that this man has not only pneumonia 
and pleuritis, but also a tendency to superficial inflammation occu- 
pying the parietes and integuments of the chest, as indicated by a 
feeling of pain and soreness in various regions of that side, but par- 
ticularly at the lower part, where the sound is clear on percussion. 
Xow, where the sound is clear on percussion, you are aware that 
no effusion of fluid exists. The fact is, that, in addition to pleuritis 
and pneumonia, the m,an is labouring under pleurodynia, with a 
tendency to inflammation in the 'superficial parts of the chest. 
Under these circumstances, we should not be surprised to find some 
oedema of the parts : and here we have a second cause for the 
greater measurement of the right side of the chest. 

These are the only points connected wiih this case to which I 
shall advert at present, except to mention that the treatment was 
obviously indicated to be antiphlogistic. You might perhaps think 
that in treating this man it was a matter of indifference whether 
you had recourse to tartar emetic, either alone or in combination 
with nitrate of potash, or to calomel and opium: but you may lay 
it down as a rule now firmlv established, that, in cases like this, 
the mercurial plan answers much belter than tartar emetic. After 
bleeding this man, then, we gave him mercury in such doses as to 
affect his system as rapidly as possible, and we followed up our 
general means of depletion by the application of leeches, which, in 
all infiammatory affections of the chest, are indicated in pj-opor- 



GANGRENE AND PLEURITIS. 57 

Hon to the pain and tenderness of the chest complained of by the 
patient. Indeed, something similar must guide us in judging how- 
far we are likely to procure relief, in cases of inflammation of any 
internal organ, by means of the application of leeches to the sur- 
face over the organ affected. No good is, ever obtained by their 
application, unless tenderness or soreness on pressure be distinctly 
observable, and the relief' obtained is always proportioned to the 
diminution of this tenderness where it existed ; where it does not 
exist, the application of leeches only leads to loss of time, 'and we 
must employ other remedies in such cases. 

There is another symptom in this case which might deceive you 
into the belief that empyema is present ; the motions of the right 
side of the chest are much more limited than those of the left. 
When you look at him stripped, you perceive an obvious difference 
between the respiratory motions on each side ; the motions of the 
unaffected are free, and much more extensive than those of the dis- 
eased side. Now, generally speaking, this is a symptom most com- 
monly observed in empyema and a few other diseases. It may 
also exist where there is extensive hepatisation of one lung, for, in 
proportion to the impossibility of air entering the diseased lung, 
will the motions of the corresponding side of the chest be dimi- 
nished. How are we to account for it in this man's case 1 The 
pneumonia is not extensive enough to cause it, and we have no 
evidence of the existence of any effusion into the pleural sac suffi- 
cient to explain it. The only way we- can account for it is by 
recollecting that the man has pleurodynia ; and, as every attempt 
at dilating the chest gives him pain, he endeavours to control its 
motions on that side as much as he possibly can. This is a fact 
well worthy of notice. It exhibits to us a beautiful provision of 
nature, which enables a person, by an intense discharge of the 
respiratory function in one lung, to compensate himself for a limited 
and imperfect performance of it in that half of the chest where it 
is limited by pain, paralysis, or disorganisation. 

As I am on the subject of pneumonia, it may be necessary to 
make a few remarks on some points connected with it, and first 
with respect to the expectoration. With the characters of true 
pneumonic sp'uta, I suppose, you are sufficiently acquainted ; you 
had many opportunities of examining the expectoration of the pa- 
tient who died of gangrene of the lung at the time he was labour- 
ing under acute pneumonia, and while hepatisation was still going 
on. But I wish to observe — and I beg you will impress this on 
your minds — that there may be cases of extensive pneumonia 
without any expectoration from the commencement of the disease 
to the period of complete resolution. A case occurred in this hos- 
pital, of a young woman, named Mary Nowlan, who had half one 
lung and the lower third of the other hepatised during a severe 
attack of pneumonia, and yet it was not accompanied at its com- 
mencement by expectoration ; there was no expectoration during 
its continuance, and resolution went on, and the lung was restored 



58 GRAVES'S CLINICAL LECTURES. 

to its healthy condition without any expectoration. She remained 
in the hospital for two months, the lung being extensively engaged ; 
and during this time she was carefully watched> but we never could 
discover anything like sputa from the beginning to the end of the 
disease. This is a very singular but instructive case. Another 
fact with regard to expectoration. A man may get an attack of 
pneumonia, and, in consequence of the rush of blood which accom- 
panies the first access of inflammatory action in the lung, may have 
at the beginning some bloody expectoration, but after a day or two 
this subsides ; and though the lung is extensively engaged, the pa- 
tient may not have any expectoration whatever throughout the 
whole course of the disease up tp the period of total resolution. I 
have seen this occurrence most distinctly marked in a case which 
I attended with Dr. Marsh. A gentleman, who had got an attack 
of acute pneumonia, had bloody expectoration for the first and 
second day, but on the third, when I saw him, it had ceased, and 
all expectoration continued absent for five weeks, at the end of 
which he completely recovered. He was an intelhgent and scien- 
tific man — knew well what was the matter with him, and enter- 
tained the old notion that all inflammatory affections of the lungs 
resolve themselves by expectoration. Hence he looked day and 
night for its occurrence with considerable anxiety, but not the least 
sign of sputa appeared. In this case the hepatisation, which was 
very extensive, became completely resolved in the course of five 
weeks, and yet it is a singular fact that there was no expectoration 
whatever, from the commencement of resolution to its termination. 
Hence you may perceive, that in pneumonia the sputa may be 
absent from the beginning to the end of the disease ; and that, 
though the hejiatisation may be very extensive, still resolution will 
occur without the slightest expectoration. Again, inflammation 
may attack a considerable portion of the lung, and the patient may 
have bloody expectoration for the first two or three days, or during 
the stage of congestion ; this may cease altogether, and the patient 
have no sign of sputa of any description up to the period of com- 
plete resolution. These are, no doubt, rare exceptions to the gene- 
ral law which regulates the course of pneumonic inflammation, in 
which we have sputa of one kind or other at every period of the 
disease; but they possess a considerable degree of interest, and it 
is of some im.portance to be acquainted with them. 

Allow me to repeat here an observation I have already made. 
The lung becomes attacked by inflammation, this goes on to hepa- 
tisation, that is, a certain portion of the pulmonary tissue which 
had been before pervious, becomes impervious; instead of being a 
soft, elastic, crepitating, sponge-like body, it becomes solid, inelastic, 
and very hke that organ from which this condition derives its name, 
the liver. One of the most curious things, the knowledge of 
which we have arrived at by the discovery of the stethoscope, is, 
that not only small, but even every extensive, portion of the lung 
may become thus solidified and altered in their texture, so that a 



GANGRENE AND PLEURITIS. 59 

return to the normal condition would seem almost impossible, and 
yet we know that a person may have nearly two-thirds of one 
lung reduced to this state of solidification, and still become after- 
wards as healthy as ever. Now, if you read Laennec^s admirable 
remarks on pneumonia, and other treatises on the same subject, yotr 
will find that the circumstances which indicate the resolution of 
pneumonia, are sputa of a certain character, and the reappearance 
of crepitus. I need not repeat here what I suppose you are all 
aware of, that crepitus commences before hepatisation, ceases oo its 
appearance, and returns again when resolution take place. The 
latter kind is what has been termed by Laennec, crepitus redux. 
JNature accomplishes the resolution of pneumonia not only by ab- 
sorption of those particles which the process of morbid action has 
deposited in the tissue of the lung, but by secretion int» the air 
cells and minute bronchial tubes, and it is the presence of this 
secretion which gives rise to the crepitus redux. Now, th(?obser- 
vations which I have made with respect to the total absence of 
expectoration in some cases ofpneumonia, apply here also; for where 
all sputa are absent, where there is no expectoration from the be- 
ginning to the end of the disease, you can have no crepitus redux. 
This observation I have made in several cases. The fact which I 
wish to impress on your attention is, that in some cases of pneu- 
monia expectoration may be completely absent: here the crepitus 
redux is never heard. Thus, in the case of Mary Nowlan, resolu- 
tion went on to the re-establishment of the healthy and normal 
condition of the lung, without the slightest crepitus being heard. 
The same thing has been observed in two or three cases by my 
friend Mr. Dwyer. It is not necessary for the resolution of hepa- 
tisation, that there should be increased excretion into the bronchial 
tubes, during the time nature is employed in absorbing the matter 
deposited in the lung. In the ordinary way it is removed partly 
by absorption and partly by excretion into the bronchial tubes. 
Sometimes, however, interstitial absorption alone seems to be suffi- 
cient for this purpose, and the cases I have' mentioned prove that it 
is in the power of nature to remove the morbid product in this way, 
without calling in the aid of the bronchial tubes. I may, however, 
remark that such cases are rare, and that resolution proceeds much 
more slowly than where free expectoration is present. 

Before I conclude, I wish to make a few observations on a case 
of erysipelas which has recently occurred in our wards. Indeed 
we have had within the last two days three cases of erysipelas, the 
disease in two instances attacking patients who lay close to each 
other. Erysipelas is at present epidemic, and has been so for some 
time. Its character and mode of treatment have been well de- 
scribed by Mr. M'Dowel, in a late pjaper, published in the Dublin 
Medical and Chemical Journal^ which I would recommend you 
to peruse attentively. It has been observed by Dr. Cusack and 
others, that when erysipelas prevails as an epidemic we may expect 
puerperal fever, and scarlatina of a bad and dangerous type.' Hence 



GO GRAVES'S CLINICAL LECTURES. 

it would appear that the same noxious quality of atmosphere which 
generates one disease, may give additional malignity to others. 

One of these cases of erysipelas occurred, in the fever ward, 
under peculiar circumstances. A young woman was admitted 
some time ago, labouring under spotted fever ; she had been many 
days ill before her admission, and continued for a considerable lime 
in an uncertain state. It is unnecessary for me to enter into any 
details regarding her treatment ; but after the more obvious indica- 
tions were answered, she was ordered to use the liquor chlorid. 
sodse, and became convalescent, or quam proxime so. Her tongue 
began to clean, the abdomen was soft, the bowels natural, the skin 
cool, and the pulse about eighty. One evening she got fresh symp- 
toms of fever, raved during the night, and next morning, when we 
visited the wards, we found her pulse accelerated, her tongue dry, 
black in the centre, and dusky-red at the edges and tip, and, in 
additiorfto this, she had some diarrhoea. The nostrils were filled 
with a semiconcrete mucus, exhaling a most offensive odour ; in 
fact, one could hardly approach her bed without experiencing 
nausea from its extreme fetor. The inside of the nares was red 
and swollen ; in short, erysipelas was seen occupying the nose, 
upper part of the face, and forehead. It had first attacked the skin 
and subcutaneous cellular tissue, producing considerable cedema, 
and frbm this it had extended to the mucous membrane of the nose. 
Erysipelas generally commences in the skin, but sometimes it has 
its origin in the mucous membrane. 

I need not tell you that' erysipelas of this cedematous character, 
accompanied by such a remarkable change in the secretion of the 
nostrils, and occurring in a person weakened by fever, was to be 
looked upon as a dangerous disease. I have not time to enter into 
any further observations on this subject, and will proceed at once 
to mention our plan of treatment. How did we treat this case? 
Not by the usual antiphlogistic means, for the patient was greatly 
debilitated. Blood-letting, leeching, emetics, and purgatives, were 
here out of the question ; however valuable they may be in ordinary 
cases, we could not use them here without risking the patient's life. 
You might think that an emetic or a purgative could do very little 
harm, and might efl^ect much good, but you are to recollect that 
the girl had nausea, thirst, bowel complaint, and a great prostration 
of strength. What then was to be done ? First, we applied a 
blister to the nape of the neck, to act partly on the brain and pre- 
vent delirium, and partly on the erysipelatous inflammation of the 
nose and forehead. How blisters act in this case I do not exactly 
know, but you are" aware that a blister applied in the neighbour- 
hood of a patch of this kind of oedematous erysipelas, is often fol- 
lowed by very good effects. Whether it is by exciting a new 
irritation, or by directing the current of the cutaneous circulation 
to another part, and causing a flow of serum thither, I cannot tell, 
but blisters certainly do give very considerable relief. So much 
for external means. 



THORACIC ANEURISM. 61 

Now with respect to interna], the only one we could give here, 
■with any prospect of benefit, was the sulphate of quinine. But the 
patient had nausea, thirst, and diarrhoea, and if you administer 
quinine by the mouth, under such circumstances, you will do more 
harm than good. I therefore prescribed it in the form of enema, 
directing five grains of quinine, combined with four of tincture of 
opium, and two ounces of mucilage of starch, to be thrown up the 
rectum every fourth hour. Under this treatment the girl began to 
improve rapidly, the erysipelas faded away, the fever declined, and 
she is now once more convalescent. I also ordered her nostrils to 
be repeatedly syringed with warm water and vinegar. 

Here, gentlemen, you perceive our treatment has been successful 
in a case occurring under very unfavourable circumstances. It is 
a case, the study of which will aflx)rd you some instruction, parti- 
cularly if you compare its symptoms, progress, and treatment, with 
the case of erysipelas which occurred in the strong healthy girl 
who is lying near, and which we are at present treating on the 
emetico-cathartic plan. 



LECTURE V. 

Case of suspected thoracic aneurism — (Edema of left arm and left side of the face ; 
probable cause or — Relations of the left vena innominata to the arch of the aorta — 
Reasons for concluding that the symptoms are produced by a solid tumour ; its 
Effects explained — Another remarkable case of thoracic tumour related — Case of 
violent and extensive pulsation of the heart depending on cerebral disease — Laen- 
nec's error concerning the indications for bleeding ; case illustrative of; use of digi- 
talis in such cases — Case of asthma, and treatment — St. John Long's liniment — 
Dropsy created by opium — Acupuncturation in anasarca. 

The object of clinical instruction being the study of disease — 
their nature and their treatment — it is our duty to apply that study 
in the manner most likely to encourage the accumulation of prac- 
tical knowledge. In accordance with this view, and in order to 
prepare you for the various emergencies that may hereafter demand 
the application of that knowledge, I shall proceed to select from 
the cases at present in the house, such as, from their singularity, 
interest, or importance, seem to claim something more than a mere 
passing notice. 

A man named James Byrne, who lies next the door in the chro- 
nic ward, and has been supposed to labour under aneurism of the 
thoracic aorta, leaves the hospital to-day. It is very probable, how- 
ever, that he will hereafter be forced to return ; for, whatever be 
the nature of his disease, it is incurable, and depends on some 
profound organic lesion. I would advise any gentleman, who has 
not attended to this very obscure case before, to take the opportunity 
of making an accurate examination of the patient during the short 
time he remains in the hospital. 

6 



62 GRAVES'S CLT^'ICAL LECTURES. 

While the phenomena of this case are still fresh in our minds, 
let US briefly discuss the question, whether this man really has 
aneurism of the thoracic aorta, and inquire whether there may not 
be some other cause to which his symptoms might be attributed 
with a more reasonable degree of probability. He was admitted 
on the 23d of October, 1834, and had been in the hospital before 
for a considerable time. He states that, eighteen months previously 
to his last admission, he was exposed to wet and cold, which pro- 
duced a feverish attack, with symptoms of local inflammation in 
the lung, manifested by cough and difficulty of breathing. These 
were soon afterwards followed by dropsical swelling, and he applied 
at this hospital for relief. After remaining under treatm.ent for 
about two months he began to improve, and left the hospital, as he 
states, quite relieved. He enjoyed tolerably good health, and con- 
tinued to work at his trade as a bricklayer until about five weeks 
before his last admission, when he was again attacked with cough 
and difficulty of breathing, accompanied by oedema of the left side 
of the chest and left arm. On examining him after his admission, 
the following phenomena were observed : — The left side of the face 
and neck was slightly cedematous ; the left external jugular vein, 
with its immediate branches, engorged and very prominent; the 
left arm and left side of the chest cedematous, and pitting on pres- 
sure ; no affection of the bronchial mucous membrane, or paren- 
chyma of the lungs, sufficient to account for the cough, can be 
detected by auscultation. Considerable dulness over the situation 
of the heart, and extending upwards over the sternal region on the 
leftside; the right sternal region sounds clear and natural. The 
heart has not been removed from its normal situation ; its pulsa- 
tions can be felt over the ordinary extent, and no more, and they 
communicate a natural impulse to the finger. On applying the 
stethoscope over the heart its sounds were found to be regular and 
natural, but on placing it higher up, over that part of the sternal 
region which was dull on percussion, a loud bruit de rape was 
heard. 

Let us analyse these symptoms. In the first place, we found the 
anasarcous swelling occupying the left side of the chest and the 
corresonding arm, and in a slight degree the left side of the neck 
and face, accompanied by a turgid state of the jugular vein. Xow, 
you may lay it down as a general rule, that where one side of the 
chest and the corresponding upper extremity is affected by ana- 
sarca, it proceeds from some cause residing in the chest. I have 
told you before that in all cases of dropsy, whether acute or chro- 
nic — whether accompanied by ascites or not — when anasarcous 
swelling appears in the trunk and upper extremities before it is 
observed in the abdomen or lower extremities, the dropsy in gene- 
ral is inflammatory, or, when not so and chronic, it proceeds from 
disease of some of the thoracic viscera, and it is in the chest alone 
that we are to look for its cause and origin. Now, applying this 
rule to the present case, we are led to inquire what is it that, by 



THORACIC ANEURISM. 63 

pressing on the veins within the chest, gives rise to engorgement 
of the superficial vessels on the left side of the neck, and to ana- 
sarcous swelling of the left arm and left side of the chest. The 
pressure must, in our patient, be applied to a portion of the venous 
system, which carries blood from tlie left side of the head and the 
left upper extremity ; in short, it must be applied to the great vein 
formed by the junction of the left subclavian and left jugulars. 
Now, this left vena innominata sive vena brachio-cephalica differs 
considerably from its fellow on the right side, which is very short, 
and nearly vertical in direction. The vein on the left side is three 
times longer, and directed transversely to the right, inclining at the 
same time downwards. It crosses behind the first bone of the 
sternum, lying in front of the three primary branches given off 
from the transverse portion of the arch of the aorta. You per- 
ceive, therefore, that it lies in a position most convenient to receive 
pressure in consequence of aneurism in any of these great vessels. 
This vein receives, before joining the cava, the internal mammary 
vein of the left side; you understand, now, why anything pressing 
on it is apt to produce engorgement of the superficial veins on the 
left side of the chest and trunk, together with cedema of these parts. 

That we are not to look for the cause of the disease in the heart 
itself, appears from various circumstances. The situation of that 
organ is not changed ; its beating can be felt only over the usual 
extent of surface ; it communicates a natural impulse to the finger, 
and when examined with the stethoscope its sounds are discovered 
to be normal and regular. Neither can we attribute the disease to 
any affection of the mucous lining or parenchyma of the lung ; the 
only morbid sounds which can be detected in the respiratory organs 
being a few slight bronchial rales. 

Now, it is sufficiently obvious that the situation of the part which 
sounds dull on percussion would suggest the idea of aneurismai 
dilatation of the arch of the aorta, or some of its immediate branches. 
But had dulness over so large a space of the chest, embracing nearly 
the vi'hole left sternal region, been produced by aneurism of the 
aorta, or any of its branches, it is evident that the aneurismai sac 
must be very large. Where an aneurism gives rise to extensive 
dulness of the chest, you may be always certain that it has arrived 
at a very considerable size ; for the dulness is caused by the imme- 
diate contiguity of the aneurismai sac to the parietes of the chest, 
and hence the dulness is always in proportion to the amount of 
lung displaced. When you applied your hand over the sac, in such 
a case as that which we are now considering, where the aneurism 
was of large size and closely applied to the parietes of the thorax, 
you would feel a very remarkable pulsation; your hand would be, 
as it were, lifted from the chest by each impulse communicated to 
the sac, and you would have palpable, unequivocal evidence of the 
cause of the dulness on percussion. Now, in the case before us, 
there was no such pulsation observed — whether we examined him 
while lying quietly in bed, or after he had walked briskly aboutjor 



64 GRAVES'S CLINICAL LECTURES. 

some time so as to excite the action of the heart and arterial 
system. Again, aneurismal sacs, as you are all aware of, before 
they produce extensive dulness of any portion of the parietes of the 
chest, point, as it were, in some particular situation, becoming dis- 
tinctly prominent, and producing an eccentric motion around them, 
in consequence of the thoracic parietes being absorbed, or yielding 
at the point of greatest pressure. 

From these circumstances, considerable doubts have arisen in 
my mind as to the cause of this man's symptoms being connected 
with aneurismal disease of the great vessels of the thorax. I am 
rather inclined to attribute the hruit de rape, and dulness of sound 
on percussion, to a lesion of a different character. Let us suppose 
that in this case a tumour has been developed in the cellular or 
glandular substances, situated in or towards the left side of the 
chest, occupying the anterior mediastinum, pushing back the lung, 
and pressing on the large vessels connected with the base of the 
heart; what are the phenomena it would naturally present '? First, 
we should have dulness of sound on percussion, corresponding in 
extent with that portion of the chest to which the tumour was 
applied ; secondly, we should have hruit de soufflei, and probably 
bruit de rape, in consequence of the pressure of the tumour on the 
aorta ; thirdly, a tumour in this situation would necessarily com- 
press some of the larger bronchial tubes, and thus give rise to 
cough and dyspncea. If a tumour presses on the trachea, or one 
of the larger bronchial tubes, why does it produce pulmonary irri- 
tation ? Not by mere pressure on the part — for the pressure is 
applied so gradually, and with such a broad surface, that its effects 
could be scarcely felt; and it might go on to produce complete 
obliteration of the tube without giving rise to any inflammation, if 
its action were limited exclusively to the part compressed. But it 
strangles, as it were, that portion of lung to which the tube belongs ; 
a certain portion of a large bronchial tube is considerably narrowed 
by the pressure of the tumour, the .free entrance and exit of air are 
impeded, and consequently that portion of the lung, which may be 
very large, is greatly deranged in its functions. Hence arises that 
sensation of distress termed dyspnoea. Again, as soon as the free 
ingress and egress of air are prevented, we have not only the 
occurrence of dyspnoea, but also other effects equally referable to 
the same cause; the blood circulating through that part of the pul- 
monary tissue is imperfectly aerated, and does not undergo the ne- 
cessary change; the secretions and exhalations from that part are 
altered and unnatural, and consequently it becomes engorged, giving 
rise to irritation, cough, and expectoration. To understand this 
aright, you should bear in mind that this portion of the lung under- 
goes the same changes that the whole of the lung undergoes in 
persons who are asphyxiated; that is, it becomes gorged with blood 
— for the moment that the black venous blood, which is carried 
into the pulmonary tissue from the right side of the heart, ceases to 
be properly aerated, that moment it stagnates in the lung, and soon 



THORACIC ANEURISM. 65 

renders it engorged. This is precisely the state of langs which 
occurs in the posterior portions of those organs in persons who die 
a Hngering death, and which has most absurdly been termed the 
pneumonia of the dying. 

But, to return to this man's case, I am inclined to think that the 
symptoms here present may with more colour of probability be at- 
tributed to the presence of a solid tumour developed in the chest, 
the nature of which I can only guess at, and that it is situated in 
the anterior mediastinum, close to the origin of the aorta. Some 
of these tumours which have been discovered in the chest are of an 
adipose nature ; some of them resemble the cerebral substance in 
colour and consistence, and others are like the steatomatous tumours 
formed in other parts of the body, 

A few months ago, Surgeon Blackley was consulted about a 
young gentleman who had been gradually attacked with symptoms 
of pulmonary irritation, cough, and difficulty of breathing. The 
disease was supposed by some to be consumption, and a physician 
who had been in attendance thought it depended chiefly on derange- 
ment of the stomach. Mr. Blackley had his doubts with respect to 
both of these opinions, and requested of me to visit and examine the 
patient. I could not detect any rales indicating the existence of 
tubercles, but over a large portion of the chest, and nearly corres- 
ponding with that part which sounds morbidly in the patient Byrne, 
there was dulness on percussion, the young gentleman had fits of 
cough and dyspnoea, and now and then difficulty of swallowing; a 
bruit de soufflet could be heard over the dull portion of the chest, 
but the sounds and impulse of the heart were regular and natural. 
I expressed a very doubtful opinion of the case, but at the same time 
stated my belief that the case was not one of tubercular phthisis, 
of empyema, or of pneumonia; and I also said that it did not seem 
to be produced by disease of the heart itself I dwelt especially on 
the existence of bruit de soufflet in the region which was dull on 
percussion, and which was somewhat removed from the heart, and 
which, from its situation, I interpreted as indicating something 
pressing either the arch of the aorta, or some of its branches. I 
was not. able to detect pulsation or any other symptom of aneurism, 
and consequently professed myself unable to say what that some- 
thing was. The result proved that, although the true cause of the 
disease did not occur to me, I had nevertheless approached the dis- 
covery as nearly as could be done without actually making it; for, 
soon after this, the young gentleman died, and on opening the chest 
a large tumour of a steatomatous character was discovered pressing 
on the divisions of the trachea, of the aorta, and on the oesophagus. 
Another case of the same kind was published some time ago in the 
Dublin Medical JournaL We are, I believe, still in the infancy of 
diagnosis, so far as regards tumours developed in the chest, produ- 
cing anomalous symptoms, and giving rise to suspicions of aneu- 
rismal or tubercular disease. With respect to the patient Byrne, I 
am inclined to think that the morbid phenomena are referable to a 

6* 



GQ GRAVES'S CLINICAL LECTURES. 

tumour of this description, and I ground my diagnosis chiefly on 
the absence of pulsation, which should be distinctly present if the 
dulness on percussion, here observable, depended on the proximity 
of an aneurismal sac to the parietes of the thorax. 

As I am speaking of pulsation, permit me to observe that, in 
some cases, where there is no actual disease present, the pulsations 
of the heart are visible over a very large extent of surface, so as to 
convey the impression that aneurismal dilatation exists. Of this I 
have lately seen a very remarkable example. In a case which I 
saw this week with Mr. Cusack, the patient's heart could be ob- 
served beating violently over the whole chest, and Mr. Cusack, 
when he laid his hand on the patient's chest, said he could not 
divest himself of the idea that there was some unnatural condition 
of the heart and great vessels. Now the violence of the heart's 
action in this case depended on disease of the brain. In some 
inflammatory or congestive diseases of the brain with a tendency 
to coma the heart labours intensely, its pulsations are quite awful, 
and it seems as if it were about to burst through the parietes of the 
chest. Again, this extraordinary action of the heart occurring in 
cerebral disease is almost invariably accompanied by a hard bound- 
ing pulse. I mention these circumstances for the purpose of putting 
you on your guard, and that you should not in such cases allow 
yourselves to be deceived, and suppose that the symptoms are to be 
met in every instance by copious blood-letting. Some cases of this 
description will bear depletion well, others will not. You know it 
was a maxim of Laennec's, that in bleeding we are to be guided 
more by the strength of the heart's action than by that of the pulse. 
I have already shown that this test does not always hold good. 
You recollect the patient who was under treatment here some time 
ago, with violent action of the heart and a hard^ bounding pulse. 
This patient, a strong healthy man, had just disemibarked, after a 
rough passage from Liverpool, during which he vomited much, 
and suffered intensely from headache, which he ascribed to the 
violence of retching. Walking along the quay, he was suddenly 
attacked with hemiplegia, and was immediately brought into the 
hospital, where he was bled and purged. Next day we found him 
still hemiplegic, and complaining of violent pain in the head. 
Active antiphlogistic treatment was used, but on the third day he 
became comatose, and was convulsed in the limbs of the healthy 
side. His face was flushed, his temporal arteries were dilated and 
pulsated violently, and his pulse was hard, while the heart pulsated 
wdth great strength. This attack came on during our visit, and I 
ordered a vein to be opened immediately. The blood flowed freely. 
When about fourteen ounces were taken the pulse suddenly flagged 
and grew extremely weak, and never again rose. He died in about 
two hours, and an ignorant person would have ascribed his death 
to the bleeding. On examination, sixteen hours after death we 
found extensive puriform effusion on the surface of the brain, to- 
gether with a large clot of blood and surrounding ramollissement. 



THORACIC ANEURISM- 67 

This was a very remarkable case, and conveyed a very important 
lesson, teaching us not to be too much led away by the violence of 
the heart's action ; for I have no doubt that here the use of the 
lancet shortened the man's life. Had such a case as this occurred 
to any of you in private practice, it would be almost fatal to your 
reputation. Here we have a patient with his face flushed, his skin 
hot, his temporal arteries throbbing violently, and his pulse feeling 
like a piece of whip-cord; he is blooded, and up to a certain point 
the pulse remains firm ; he then begins to sink rapidly, and expires 
in two or three hours. Bear in mind, then, that a state of the sys- 
tem may exist, in which the heart's action is intense, and the pulse 
hard and bounding, and yet where bleeding to any amount will be 
badly borne.* Such cases are generally connected with inflamma- 
tion of the brain, accompanied by a tendency to coma. Here you 
must bleed with great caution, let the quantity you take away be 
moderate, and rather rely upon large relays of leeches and strong 
purgatives for removing the cerebral symptoms. You may after- 
wards endeavour to moderate the heart's action by the use of digi- 
tahs and opium ; a grain of the former, and one-twelfth of a grain 
of the latter, made into a pill with some extract of hops, may be 
given every second hour, until it begins to produce some effect on 
the heart's action, when it may be either discontinued or given at 
longer intervals, as the circumstances of the case may require. 
Where, after bleeding and other antiphlogistic measures, the pulse 
continues high, and the action of the heart violent, I can recom- 
mend digitalis very strongly, and the small portion of opium here 
combined with it can do no harm. Combined in small quantities 
with digitalis, opium does not produce any tendency to determina- 
tion to the head, and it prevents the digitalis from sickening the 
stomach. I have frequently employed it, and found great benefit 
from its exhibition. I may observe, that when you are anxious to 
secure the full sedative effects of digitalis on the heart and pulse, 
you must give it in large doses. In small quantities it does not act 
well, and seems rather to produce a tendency to excitement of the 
heart. 

There is another patient about to leave the hospital to-day, on 
whose case I wish to make some observations. This young man, 
whom you have seen lying in the chronic ward, in the bed next 
but one to Byrne's, caught cold about seven or eight months ago, 
followed by cough, wheezing, and dyspnoea, which, after a month 
or six weeks, subsided. About two months before he came into 
the hospital, he renewed his cold, and with it the cough and dys- 
pnoea returned. On his admission he complained of difficulty of 
breathing, which attacked him every night ; he went to bed well, 

* [Less frequently we should say in inflammations proper, than in those 
affections of the brain which depend upon some general diseases, such as kid- 
ney or liver affections of the chronic kind, and occasionally in continued fevers. 
In such cases, cupping and blistering are more frequently of service than large 
bleedings. — Ed.'] 



68 GRAVES'S CLINICAL LECTURES. 

and slept tranquilly for two or three hours, and then was awakened 
by pain and sense of tightness in the chest, with great dyspnoea. 
When the paroxysm came on, it compelled him to get up and walk 
about the room, gasping for breath ; and, after continuing for two 
or three hours with great dyspnoea, wheezing, anxiety, and cough, 
went off with free expectoration and sweating. As soon as the 
sweating and expectoration appeared, he lay down without any 
inconvenience, and slept quietly until morning. The only addi- 
tional symptom he complained of was palpitation of the heart, 
which sometimes affected him when employed at hard labour. On 
examining the lungs there was nothing found except a few bron- 
chitic rales. The heart was normal in its action, and no morbid 
sound could be detected by the stethoscope. In addition to this, 
you will recollect that the man was in the prime of life, had a full 
and well formed chest, a quiet pulse, regular bowels, and a good 
appetite. 

Here you perceive a man from repeated colds gets chronic irri- 
tation of the bronchial tubes, and this induces asthmatic paroxysms, 
which comes on, as is usual in such cases, at a certain hour of the 
night. It was plain, therefore, that he was labouring under a well 
marked form of asthma, a disease which, in its pure and simple 
state, is seldom met with in hospitals, being generally observed in 
connection with disease of the heart, or long-continued bronchitis 
in old persons. Chronic bronchitis is one of the most common 
causes of asthma ; indeed, you will scarcely ever meet a patient 
who has been subject to chronic irritation of the bronchial tubes, 
who does not also labour under more or less asthmatic dyspnoea. 
The disease is generally met with in persons advanced in life, and 
who have suffered from repeated attacks of bronchitis ; it is not 
usual to find it in so young a man as this patient, and presenting, 
as he does, such very slight symptoms of derangement of the bron- 
chial mucous membrane. 

This case exhibits a remarkable proof of what may be done by 
simple means in relieving an urgent disease. The man was, with 
the exception of asthma, in good health ; his bowels were regular, 
his appetite good, his pulse tranquil, and the signs of pulmonary 
irritation trifling. There was no necessity, then, for administering 
remedies to improve the tone of the digestive organs, nor were we 
authorised to use the lancet or apply leeches. I therefore confined 
my attention to two points : the application of irritants to the neck 
and chest externally, and the internal use of remedies calculated to 
relieve bronchial irritation. I ordered him to rub the nape and 
sides of the neck, and the fore part of the chest, with a liniment 
composed of strong acetic acid, 5ss., spirit of turpentine, 3iij., rose 
water, §iiss., essential oil of lemons a few drops, and yolk of egg 
in sufficient quantity to suspend the turpentine. This liniment is 
an imitation of the celebrated liniment of St. John Long. I gave 
a bottle of the real liniment to Dr. Apjohn, to analyse, and he thinks 
it consists of acetic acid, spirit of turpentine, and two animal mat- 



ST. JOHN LONG'S LINIMENT. 69 

ters, one containing azote, the other not; the latter probably some 
species of fat, probably goose-grease. Now this fat did not exist 
in St. John Long's liniment in the form of soap, it was evidently 
some kind of fatty matter blended with water, probably by means 
of trituration with yolk of egg. The active ingredients are spirits of 
turpentine and strong acetic acid. This liniment should be applied 
by means of a sponge. It acts as a rubefacient, and generally in- 
duces an eruption of small pimples after a few applications. The 
spirit of turpentine must be well mixed with the water (which 
ought to be added to it gradually) by means of yolk of egg^ before 
the acetic acid is added. 

With this hniment our patient was desired to rub the forepart of 
the chest, and the nape and sides of the neck. It was applied to 
the chest with the view of relieving the bronchial irritation, and 
we ordered it to be rubbed over the nape of the neck, along the 
course of the cervical portion of the spinal marrow, and over the 
sides of the neck along the course of the pneumogastric nerve, 
because all the organs to which the latter nerve is distributed, are 
evidently affected in cases of spasmodic asthma. Thus a paroxysm 
of asthma is not only attended with increased action of the heart, 
dyspnoea, and hurried breathing, but also with marked derangement 
of the stomach, particularly towards the termination of the fit, 
when the patient generally has a feeling of uneasiness in the sto- 
mach, with flatulence and a sense of fulness, induced probably by 
the derangement of circulation in the lung. You are aware of 
the close sympathy which exists between the stomach and lungs, 
and you must have been struck with the fact, that stimulant and 
irritating remedies applied to the epigastrium often relieve affections 
of the lung more completely than when applied to the chest. Thus 
in using the tartar emetic ointment for the relief of hooping-cough, 
it has been found to act most beneficially when applied over the 
region of the stomach ; and the same thing may be said of Roche's 
embrocation, which does more good when rubbed over the spine 
or epigastrium, than when applied to the parietes of the thorax. 
On these principles, I ordered the counter-irritation to be applied 
over the course of the cervico-spinal and pneumogastric nerves, 
over the chest, and subsequently over the stomach. 

This liniment in a very short time produces redness and heat of 
the parts to which it is applied, and it is more than probable that its 
effects are not limited to temporary rubefacience, but that it also 
acts on the nervous system. We have innumerable proofs that 
turpentine exercises a special influence over the nervous system, 
and we know that it is rapidly absorbed even without the aid of 
friction. I fear, however, that we shall never be able to confer on 
our liniment all the wonderful properties attributed to that of St. 
John Long. You know it has been asserted that St. John Long's 
liniment never reddened the skin, except over the exact spot where 
disease was situated. I was assured by a young lady who used 
this Hniment, that she rubbed it all over the chest, and that it pro- 



70 GRAVES'S CLINICAL LECTURES. 

duced no discoloration of skin, except in two spots where she felt 
pain. She at first mentioned but one spot which was painful, but 
St John Long, having applied the liniment himself, told her she 
had deceived him, and that there was pain in another spot. It had 
other effects equally miraculous. An eminent Dublin lawyer de- 
clared that it drew nearly a pint of water from his head, and Lord 
Ingestre testified that it extracted quicksilver from his brain ! 
These, and other wonderful stories, told by several persons of dis- 
tinction with a full belief in their authenticity, furnish a useful 
lesson to mankind, showing that gross credulity is not confined 
exclusively to the poor and the ignorant, but may be found among 
the highest classes of society. It is a singular fact also, and illus- 
trative of the tendency which exists in human nature to deceive 
and be deceived, that notwithstanding the repeated failure, and even 
fatal effects, of St. John Long's applications, many persons still 
regard his opinion as oracular, and look upon his remedies as ines- 
timable discoveries. When I mentioned to the gentleman who 
brought me the bottle of liniment, that St. John Long himself died 
of phthisis, and brought this forward as a strong argument against 
the infallible efficacy of his remedies, he said that this very circum- 
stance was one of the most remarkable proofs of his sagacity, for 
St. John Long had always maintained that the liniment was not 
suited to his own case, and that there was something in his consti- 
tution which neutrahsed its good effects ; and so it happened, for 
when he applied the liniment to his skin it did not produce the red 
spots which usually resulted from its application in other persons. 
In fact, such was the credulity of St. John Long's patients, that his 
death passed among them as the strongest proof of the infallibility 
of his medicines. Indeed he is considered by many of our nobihty 
as a sort of medical martyr, who, having sacrificed life in the 
accomplishment of his mission, rising from earth, let his prophetic 
mantle fall on the highest bidder ! 

But to return to our patient. In this case the liniment did a 
great deal of good, but it was not the only means we employed. 
We observed that the asthmatic paroxysm came on every night, 
continued for two or three hours, and then went off w'ith free ex- 
pectoration and sweating. In order to prevent this, we gave him a 
draught, which he was to take when awakened by the pain and 
sense of tightness in his chest. He took this, and it had the effect 
of arresting the paroxysms, so that he no longer found it necessary 
to leave his bed. That this remedy had succeeded in averting the 
disease, was plain from the following circumstance: — one day the 
clinical clerk had omitted to repeat his draught, and he consequently 
got no medicine ; on that night the asthmatic paroxysQi returned 
and went through its usual course as before. This draught was 
very simple^ being composed of half a dram of tincture of hyos- 
cyamus, half a dram of vinegar of squills, and the same quan- 
tity of ipecacuanha wine in an ounce of camphor mixture. It is 
scarcely necessary for me to explain the nature of the ingredients. 



CHRONIC BRONCHITIS. 71 

The tincture of hyoscyamus possesses narcotic and antispasmodic 
properties, and ipecacuanha and squill are known to have great 
efficacy in disease of the bronchial mucous membrane, being both 
promoters of expectoration, and the latter also acting on the urinary 
organs. Without, however, attempting to explain the precise 
mode in which each of these ingredients acted, it will be sufficient 
to state that the combination had a beneficial eftect; and checked 
the asthmatic paroxysms. We persevered in using it, as well as 
the liniment, until all tendency to asthma had disappeared, and the 
normal state of the function of respiration became perfectly re- 
established. 

There is in the male chronic ward a patient named Garret Kane, 
to whose case I shall for a few moments draw your attention. This 
man is about forty-five, and, like most of his countrymen who have 
been addicted to whiskey, he is beginning to show the fatal eflfects 
of intemperance. He had been ill for several months before he 
came into the hospital, and is at present labouring under general 
anasarca, affecting the chest, upper and lower extremities, accom- 
panied by an accumulation of fluid, but not very extensive, in the 
cavity of the peritoneum. I do not intend here to inter into the 
general pathology of dropsy, or to inquire what was its origin in 
this instance; I shall confine myself to an explanation of the rea- 
sons which have induced me to select the plan of treatment I have 
adopted. In the first place, it is a case of chronic dropsy; secondly, 
it is unattended by fever ; thirdly, it is a case in which mercury 
has been used with some temporary relief, but the disease returned 
afterwards in a worse form ; lastly, it is dropsy accompanied by 
obstinate diarrhoea, and therefore contra-indicating the use of pur- 
gatives or even of diuretics, for you are aware that the whole class 
of diuretic medicines acts more or less on the intestinal canal. I 
may mention here, acetate and nitrate of potash, turpentine, colchi- 
cum, squill, and many other remedies of the same kind. All 
diuretics act either as purgatives, or they have a stimulant and irri- 
tating effect on the bowels. This patient has bowel complaint, 
and therefore we are prevented from giving diuretics or purgatives ; 
and the absence of inflammatory symptoms precludes the employ- 
ment of the lancet or cupping-glasses. You perceive that our field 
for practice is extremely limited ; we dare not bleed, cup, purge, 
give mercury, or diuretics ; the nature of the case contra-indicates 
the use of all these remedies, and hence we are deprived of the 
power of using the most energetic agents employed in the treat- 
ment of dropsy. What then is to be done ? Having observed that 
the man's appetite and thirst are very great, and that his urine con- 
tains a large quantity of albumen, that he has no fever, and no 
symptoms of local inflammation, I decided at once on trying the 
efficacy of Dover's powder in doses of a scruple in the day, divided 
into four pills, and gradually increased until it amounts to half a 
dram, or two scruples, in the twenty-four hours. A species of 
analogy exists between cases of this kind and cases of diabetes; in 



72 GRAVES'S CLINICAL LECTURES. 

both there is the same tendency in the blood to part with its watery 
constituents, in both the same inordinate thirst and craving appetite 
are observed, and in both there is the same deposition of animal 
matter in the urine. The principal difference between them is, 
that in one case the watery fluid is effused into the cellular sub- 
stance and peritoneal cavity, while in the other it is eliminated 
from the system through the medium of the kidneys. It was this 
analogy which led me to adopt Dover's powder in the treatment of 
this man's case. Last year we had a patient here under treatment 
who was dropsical, and at the same time passed five quarts of urine 
daily ; before I had recourse to the ordinary treatment for dropsy, 
I determined to try the use of Dover's powder. The disease yielded 
rapidly to this plan of treatment, and the man left the hospital quite 
relieved. 

In the patient Kane a small sore was formed on one of the lower 
extremities, perforating the skin and cellular substance to the depth 
of two or three lines ; through this aperture a great deal of the 
anasarcous fluid has drained, and still continues to flow off. This 
is a very fortunate circumstance, as it will tend to prevent any ex- 
cessive accumulation in the cellular membrane. Previous to its 
occurrence I had ordered the scrotum and prepuce, which were 
enormously distended, to be punctured with a needle. The best 
mode of doing this is to prick the part quickly, so as to give as 
little pain as possible, the point of the needle should merely pene- 
trate the true skin, the punctures should vary in number from 
twenty to fifty or sixty, according to the size of the part and the 
extent of the effusion, and they should be at least half an inch 
asunder. By observing these rules you will succeed in evacuating 
the water without running the risk of exciting erysipelas, which 
in such cases frequently leads to disastrous consequences. Punc- 
turing with a lancet is not so good as with a needle, it is much 
more apt to excite irritation in the parts, and thus lead to the super- 
vention of erysipelatous inflammation. The judicious application 
of acupuncturation, in cases of chronic dropsy, often accomplishes 
a great deal, for when the external anasarcous oedema is thus 
drained away, the fluid in the peritoneal cavity is more rapidly 
absorbed; in some cases, indeed, the good effects of external drain- 
age on the ascites are so rapid, that we are almost tempted to 
believe that some direct communication may exist between the 
subcutaneous tissue and the apparently shut sac of the peritoneum. 
Be this as it may, the good effects in some cases are as decisive as 
if such a communication existed. This phenomenon countenances 
the hypothesis of the possibility of fluids percolating through lining 
membranes. 

Note. — In the foregoing lecture I have adverted to a subject not 
hitherto sufficiently considered by pathologists, viz., the immediate 
effects produced in the bronchial tubes and pulmonary tissue when 
an internal tumour presses on one of the bronchi. The result is a 
certain degree of cough, expectoration, and dyspnoea. In some 



SECONDARY SYPHILIS. 73 

cases the bronchial inflammation thus produced may go on to 
actual ulceration, which authors have been too much disposed to 
regard as being mechanically produced by the local irritation of 
pressure. Professor Albers, of Bonn, cites one case in which a 
scirrhous tumour of the oesophagus produced ulceration of the 
neighbouring compressed bronchus, but he says nothing of the 
manner in which this effect was accomplished. In some cases, no 
doubt inflammation may be propagated from the morbid growth, 
but in tumours I speak of, no evidence of inflammation existed. 
Professor Albers's observations on this subject may be seen in his 
paper on Widening of the Pulmonary Artery, Rusfs Magaxin 
fur die gesa?nmte Heilkunde, 42 Bandf 1 Heft, p. 177. 



LECTURE VL 

Case 0^ secondary symptoms which made their appearance soon after a mercurial 
course ; method of treatment — Case of syphilitic eruption — Mouth suddenly affected 
by a small quantity of mercury — Effects of this on the progress of the cure — Ear- 
ache preceded by rigors coming on during the course of fever ; danger of; treatment 
— External tenderness ; value of, as a symptom in inflammations of brain, lungs, 
abdomen, &c., Sec, — ^ Vomiting considered as a symptom in fever ; its treatment — 
Chronic rheumatism; successful treatment of — Obstinate case of arthritis ; cure of 
by local applications — Observations on the effects of mercury applied locally — Case 
of syphilitic iritis ; action of belladonna in. 

You have observed that we have two cases of syphilis under 
treatment-— one in the female, the other in the male chronic ward. 
They possess no peculiar interest beyond the ordinary run of syphi- 
litic affections, still they deserve a share of your attention ; for it is 
on your experience of individual cases, much more than on the 
knowledge derived from books, that your treatment of this obscure 
and Protean malady will depend. 

It is now more than a' year since the female patient received the 
syphilitic poison into her constitution. What the nature of the 
primary sore was we cannot ascertain, but from the account she 
has given, it seems to have been true chancre. Some time after 
this occurr^j she got sore throat, articular pains, and an eruption, 
for which she was treated in this hospital about ten months since, 
and dismissed apparently cured. The disease, however, returned 
in a few weeks, and she has been labouring under its effects up to 
the present moment. Three circumstances in this case demand 
our attention: first the re-appearance of syphilis after a mercurial 
course —-for she was mercurialised here soon after her first admis- 
sion ; secondly, she exhibits a degree of syphilitic cachexy, being 
rather pale and emaciated ; and, thirdly, the slow progress which 
the disease has made in her system, being limited to a few blotches 

7 



74 GRAVES'S CLINICAL LECTURES. 

on the skin, some periostitic swelling of the bones of the leg, pains, 
and slight arthritis. 

In treating this case I intend to give mercury, so as to affect her 
system ; and, having accomplished this, I shall keep her under its 
influence for some time. I shall also, should it appear necessary, 
order her a free allowance of the decoction of sarsaparilla. Under 
this treatment you will find that the eruption will soon disappear, 
the periostitic pains and swelling be removed, and the constitution 
begin to improve. She has been ordered three grains of blue pill, 
and half a grain of calomel, three times a day — a quantity which 
you will generally find sufficient to bring on mercurial action in 
females. I have no doubt but that the disease will, in this case, 
yield to mercury in a very short time, and that her health will be 
completely restored. The failure of mercury in producing a per- 
manent cure, on a former occasion, is no argument against its 
employment here ; if there were no syphilitic taint in question, I 
do not know any remedy by which the cutaneous affection and the 
periostitis could be more effectually relieved. On another occasion 
I shall speak more at large upon this important subject, and shall 
bring forward facts in proof of the assertion, that mercury may 
fail to eradicate the effects of the venereal poison at a certain period 
of the disease, and may nevertheless be capable of curing the dis- 
ease effectually at a future time. This may appear paradoxical, 
but it is not the less true. 

The other patient, John Kelly, presents an eruption of red scaly 
blotches, extensively diffused over the trunk and extremities, and 
closely resembling psoriasis. This man, like many others, denies 
the occurrence of a recent syphilitic taint, and gravely states that 
it is some years since he exposed himself to infection. Instances 
of this kind are to be met with every day; patients will not tell the 
truth about these matters, and false statements tend to throw a 
darker shadow over a disease in itself sufficiently obscure. How- 
ever, in this case, the poison seems to have confined its effects to 
the cutaneous surface ; there is no affection of the throat, perios- 
teum, or joints. The eruption covers almost every portion of his 
body ; it made its appearance two months before admission, and 
was preceded by feverish symptoms and pains in the larger articu- 
lations. 

In undertaking the treatment of this case, there is one practical 
point to be held in view. The man's general health fs good, his 
strength undiminished, and his circulation active. I therefore 
ordered him to be blooded, and have kept him for eight or nine days 
on antimonials and low diet. By preparing him in this way, I 
knew that the mercury which I intended to give him would act 
more rapidly on his system ; and such was the case — for on the 
second day after he commenced using it his mouth became affected. 
But here a difficulty arose, which, in cases of this description, is 
apt to embarrass our treatment : the mercurial influence appeared 
much sooner than I expected or wished. He had been ordered 



SYPHILITIC ERUPTION. 75 

three grains of blue pill, and half a grain of calomel three times a 
day; and on the second day, before he had taken six pills, saliva- 
tion commenced. Now, in all cases where mercury affects the 
mouth sooner than you desire, and as it were in spite of you, it 
will not do as much good as where its action proceeds regularly 
and in accordance with your purpose. It is a general rule, that 
most benefit is to be expected from, mercury where its action is 
regularly progressive, or where the quantity taken is in proportion 
to the effect produced on the system. Hence we look upon it as an 
unfavourable occurrence, when a small quantity of mercury occa- 
sions sudden and copious salivation ; such an event deranges our 
calculations, and tends to embarrass our practice. Now, in this 
case the patient, after taking five pills, became salivated on the 
second day. We found we had been going on too fast ; it was 
necessary therefore to pause, but not desist. We accordingly re- 
duced the quantity of mercury to three grains of blue pill, and half 
a grain of calomel, to be taken every second night. By these means 
we kept up a slight discharge of saliva, and the man's symptoms 
began to improve. The eruption is now disappearing rapidly, and 
it is to this point I wish to call your attention. What are the marks 
which indicate the subsidence of an eruption of this kind, and by 
what criterion are you enabled to judge of the progress of the 
cure ? When the parts are about to return to the healthy condition,, 
three circumstances occur ; first, the vivid red or copper colour of 
the eruption begins to fade ; secondly, the heat of the affected parts 
become reduced ; thirdly, the excessive secretion of morbid cuticle 
is arrested, and the quantity of minute scales covering the blotches 
diminished. In such cases, the affected parts of the skin are highly 
vascular, and the secretion of cuticle is morbidly excessive in 
quantity; hence the continued desquamation from the surface of 
the blotches. You should, therefore, attend not m.erely to the colour 
of the eruption, but also to the quantity of minute scales on each 
blotch, when you wish to ascertain whether an eruption is fading 
or not. You can judge of this by your eye, or you can tell it by 
passing your finger over the diseased surfaces. The. fading of the 
colour of the. eruption, the decrease of the elevation and roughness 
in the blotches, and the gradual disappearance of the minute scales — 
these are the circumstances by which you can ascertain the subsi- 
dence of a syphilitic eruption. As the cure progresses, you find the 
parts assuming a more natural appearance ; the same quantity of 
morbid cuticle is no longer thrown out by the affected spots of 
corium ; the blotches become smooth and lose their elevation, and, 
finally, the red colour of the skin disappears. Of all the symptoms, 
discoloration of skin is the last to recede, and it generally happens 
that enough has been done in the way of treatment long before the 
skin resumes its natural coniplexion. If you were to continue the 
administration of mercury until the natural colour returned, you 
would very often push it to a useless and even dangerous extent. 



76 GRAVES'S CLINICAL LECTURES. 

In such cases, a faded brownish or dirty tinge remains long after 
the re-establishment of healthy action. 

There is a case in the female fever ward which requires a pass- 
ing observation. A young woman, previously in the enjoyment of 
good health, was seized with symptoms of fever after exposure to 
cold ; she got rigors, followed by headache, hot skin, thirst, nausea, 
and acceleration of pulse. It is unnecessary for me to detail the 
symptoms which attended her illness during the past week ; I shall 
content myself with pointing out the symptoms which particularly 
attracted my attention to her case on Saturday morning. At that 
time her fever had increased ; she complained of severe headache 
and restlessness; had foul tongue, thirst, and symptoms of gastro- 
intestinal irritation. Such matters, however, demand no very par- 
ticular consideration ; what chiefly fixed my attention was the 
occurrence of slight and transient rigors during my examination : 
I observed her shuddering three or four times in the space of a few 
minutes. On questioning her respecting these brief rigors, she in- 
formed me that they had occurred with more or less frequency for 
the last three days. Now, whenever you meet with a symptom of 
this description in fever, be on your guard ; watch the case with 
anxious, unremitting attention, and never omit making a careful 
examination. It is in this way that one of the worst complications 
of fever — treacherous and fatal disease of the brain — very often 
commences. On examining this girl, we found that she had not 
only headache, but also acute pain referred to the left ear, the exter- 
nal meatus of which was observed to be hot and tender to the touch. 
In addition to this, we were informed by the nurse that she had 
been seized with a sudden fit of vomiting shortly after we left the 
ward on the day before. Here was an array of threatening symp- 
toms calculated to awaken attention in any, even the most heedless 
observer. A patient, after exposure to cold, is attacked with symp- 
toms of fever ; she has headache and restlessness ; she then begins 
to complain of acute pain in the ear, darting inwardly towards the 
brain ; and, finally, is seized with sudden vomiting. Under these 
(Circumstances, it is not difficult to form a diagnosis, and there can 
be little doubt but that the phenomena here present were indicative 
of incipient inflammation of the membranes of the brain. . It is not 
easy to say whether in such cases the inflammatory affection of the 
membranes precedes the external otitis, or whether the inflamma- 
tion commences in the external ear and spreads inwards, though I 
am inclined to adopt the latter supposition, and the circumstance 
of the fever and earache arising from cold seems to give an addi- 
tional degree of probability to this view of the question. Be this 
as it may, there could be no doubt but that this girl was, on Satur- 
day, labouring under incipient inflammation of the membranes of 
the brain, as denoted by headache, rigors, acute pain in the ear, and 
vomiting. 

Here let me observe, gentlemen, that, in cases of this description, 
I look on the occurrence of external tenderness, not merely as an 



INFLAMMATION OF THE BRAIN. 77 

indication of internal disease, but also as a favourable symptom. 
I have remarked that in all cases where this happens, the physician 
becomes more speedily and sensibly aware of the existence of inter- 
nal disease, and the remedial means employed act with a more de- 
cidedly beneficial effect. I would prefer having to deal with an 
inflammatory affection of the brain or bowels, accompanied by 
external tenderness^ and would feel much more certain as to the 
result, than if this symptom were but ftiintly marked, or totally 
absent. This observation is founded on experience. 

In treating this case, you have seen tliat I have ordered relays of 
leeches to be applied in the vicinity of the affected ear until the 
earache has ceased. . I have long followed this practice of applying 
a number of leeches in succession for the relief of local inflamma- 
tion, and I can state with confidence that the result has been, in the . 
majority of cases, highly satisfactory. Some prefer the appHcation 
of a great many leeches at once; but my experience speaks strongly 
in favour of the practice of applying a small number, repeated at 
short intervals, until the violence of the local inflam-mation is sub- 
dued. Relays of six or eight leeches will suffice in the majority of 
cases of pectoral, cerebral, or abdominal inflammation.* In some, 
however, when the attack is violent, fifteen or twenty must be 
applied at once; each succeeding relay may consist of a smaller 
number than that which preceded it. In this manner I have main- 
tained a constant oozing of blood from the integuments over an 
inflamed organ for twenty-four, or even thirty-six hours. In addi- 
tion to this, I determined to bring her system rapidly under the in- 
fluence of mercury, and, with this intent, administered calomel to 
the amount of a scruple in the twenty-four hours. These means 
have acted favourably, and she feels much better to-day. (This 
patient perfectly recovered.) 

Allow me to make one observation more which this case suggests. 
This young woman, you recollect, had, on her admission, some 
epigastric tenderness, which we removed by leeching, and she 
remained free from any symptoms of gastric irritation until last 
Saturday, when she got a sudden attack of vomiting. Now, ^?^ all 
feverish complaint s^ where, during the course of the disease, the 
stomach becomes irritable icithout any obvious cause, and where 
vomiting occurs ivithout any epigastric tenderness, you may expect 
congestion, or incipient inflammation, of the brain or its mem- 
branes. If called to a case of scarlatina, where there is severe 
vomiting, and perhaps diarrhoea, unaccompanied by thirst or 
epigastric tenderness, what should your practice be? Are you to 
direct your attention to the alimentary canal, and endeavour to 
arrest these symptoms? No. The vomiting here depends on 
active congestion of the head, and such cases are very apt to end 

* [This practice is often excellent. As the American leechef? are smaller than 
the European, to produce the same effect twice the number should be applied 
if the leeches be large, but if small three times as many would be about equal. — 

7* 



78 GRAVES'S CLINICAL LECTURES. 

in coma, convulsions, or death, from disease of the brain. You 
are all aware, that in cases of injuries of the head, followed by 
congestion of the brain, vomiting is one of the most prominent 
symptoms. The same thing occurs in febrile affections, attended 
with determination to the head. You are not to conclude that a 
fever is gastric, because it commences with nausea and vomiting; 
this is a serious, and very often a fatal, mistake ; yet I am sorry to 
say it has been committed by many practitioners, and I have been 
guilty of it myself In such cases, you should not waste time in 
attempting to relieve gastric irritation by cold drinks, and leeches 
to the epigastrium, or to check diarrhoea by chalk mixture and 
opiates ; you should direct your attention at once to the seat and 
origin of the mischief, and employ prompt and effectual means to 
relieve the cerebral congestion. Where the disease sets in with 
severe vomiting, unaccompanied by distinct evidences of gastric 
inflammation, whether it be common fever, or scarlatina, or 
measles, or small-pox, I commence the treatment by applying 
leeches to the head, convinced that in this way I shall be most 
likely to prevent an approaching dangerous congestion of the brain. 
T am anxious to impress this observation on your minds, because 
1 am fully sensible of its importance, and feel certain that you will 
derive much advantage from, bearing it in recollection during the 
course of your future practice. 

The next affection to which I shall draw your attention is chro- 
nic rheumatism, of which we have a well-marked instance in the 
man who lies in the chronic ward immediately under the window. 
He complains of pain, weakness, and numbness of the lower extre- 
mities, for which he used the decoction of sarsaparilla and minute 
doses of corrosive sublimate, for a fortnight, without any obvious 
improvement in his symptoms. His complaint is of considerable 
duration, it being now fifteen weeks since he was first attacked. 
This, I need not tell you, is a very unpromising feature in his case. 
When rheumatism has continued for three or four months, it be^ 
comes a very intractable disease ; indeed, there is scarcely any 
affection which tasks the ingenuity, and tries the patience, of a 
medical man more than chronic rheumatism. In this case, how- 
ever, we have been so fortunate as to hit on a remedy suited to the 
complaint ; the man has been rapidly improving within the last 
fortnight, and is now nearly well. You will recollect that, when I 
undertook the treatment of this case^the patient was free from 
fever, his general health but little impaired, his pulse tranquil, his 
appetite good, no remarkable tenderness or redness of the joints — 
in fact, nothing to indicate the existence of acute local inflamma- 
tion ; consequently, it would have been useless to have recourse to 
leeches or blood-letting, or to administer antimonials, nitre, or col- 
chicum. In such cases as this a different line of practice must be 
followed; you must have recourse to stimulant diaphoretics — reme- 
dies which will increase the secretion from the skin, at the same 
time that they exercise a stimulating action On the nervous and 



CHRONIC RHEUMATISM. 79 

capillary systems. Accordingly we prescribed for this man the fol- 
lowing electuary, of which he was to take a teaspoonful three 
times a day: — Powdered bark 3j-) powdered guaiacum 5j-> cream 
of tartar 5j., flower of sulphur 5ss., powdered ginger 5Jm to be made 
into an electuary with the common syrup used in hospitals. The 
guaiacum not only acts on the nerves, tending to remove chronic 
pains, but also acts on the skin : you will fiad these, and other pro- 
perties possessed by it, detailed at large in your works on Materia 
Medica. Whether given in the form of powder or tincture, it often 
proves an extremely useful remedy in cases of chronic rheumatism, 
where no symptoms of active local inflammation or general fever 
exist ; where either of th.ese are present it is inadmissible. Ginger 
has also a stimulant eflect, although its action is much more limited. 
It is a favourite domestic remedy, and is very frequently prescribed 
by our rival candidates for therapeutic celebrity — old ladies — in 
cases of chronic, or, as they term it, cold rheumatism; and I must 
confess that I have seen some benefit derived from their specific — 
ginger tea. With these we combined sulphur, which exerts a pecu- 
liar stimulant operation on the skin and alimentary canal. Sulphur 
is an extremely active remedy, and singularly penetrating in- its 
nature, finding its way into many of the secretions and most of the 
tissues of the body. You will find it in the urine in the form of 
sulphates, and it is exhaled from the &kin and mucous membrane 
of the bowels in the form of sulphuretted hydrogen. Having said 
so much respecting sulphur, you will perhaps inquire why I pre- 
scribed the bark? It is not easy to give a satisfactory explanation 
of this ; but we know, from experience, that in cases of rheumatism, 
after fever and local inflammation are removed, bark and other 
tonics have been found extremely valuable. The cream of tartar 
is given with a view of tempering the other stimulant remedies, 
it being known to possess cooling and aperient properties. The 
whole form a combination which is similar in its composition to a 
well-known popular remedy for rheumatism — the Chelsea Pen- 
sioner. 

Having thus explained the general tendency of these medicines, 
and mentioned that they are to be made up into an electuary, it 
only remains to speak of the efl^ect produced, and the dose or quan- 
tity to be given. I have stated that the ordinary dose is a teaspoon- 
ful three times a day ; this, however, v^'ill be too much for some, 
and too little for others. The object in every case should be to 
keep up a mild but steady action on the bowels, and to procure a 
full alvine discharge at least once a day. If the dose mentioned 
already does not answer this purpose, it must be increased; if the 
bowels are too free, it must be diminished. You should never omit 
making regular inquiries after the state of the bowels, while the 
patient is using this electuary; for if these matters are neglected, 
the patient will not obtain the full benefit to be derived from it. 
Besides opening the bowels, this electuary acts on the skin, and fre- 
quently causes a rapid disappearance of the disease. I need not 



80 GRAVES'S dJOTCAL LECTUSBS. 

s^y that, io addition to this, I ordered warm baths ; they coincide 
In efiect with the electuaiy, acting on the skin, and tending to 
relieve thp rfaeonnatic pains. 

There is another very remarkable case bearii^ some affinity to 
the preceding, on which it may be necessary to o&r a few remarks ; 
I aliode to the {latient with sweating arthritis, to whom I drew yoor 
allention this morning. This poor man, who is somewhat advanced 
io life, has been laboaring for several months imder inflammation 
of the joints of a rheomatic character, manifesting itself by pain, 
sliSbess, swelling, and probably some slight e^iision into the syno- 
vial membranes. These symptoms were accompanied by profuse 
and constant perspirations, with a tendency to diarrfacea — circum- 
stances which caused a manifest deterioration of his health and 
streDgth ; be became pale, cachectic, and emaciated, fiis case had 
beeo very tedious and intractable; he had been a long time in the 
hospital, and had used all the most appropriate remedies, but with- 
out any appreciable improvement; his joints remained stiff, painful, 
and almost useless; he was greatly reduced in strength, and entirely 
confined to his bed. In addition to this, his pulse continued unre- 
dnced io frequency, and this is always a bad sign ; cases of rheu- 
matic arthritis, attended by prolonged excitement of the circulation 
and copious sweating, are generally found to exhibit an intractaUe 
chronicity, and too often terminate in renderii^ the unfortunate 
patient a cripple for life. 

Now in this case many remedies had been tried without efi^t, 
and the state of the man's constitution, combined with the circum- 
stance of his haviDg a teodency to bowel complaint, contributed to 
reduce stiil finther the scanty list of our remedial agents. Altera- 
tive remedies, to a^ct the general system, were almost entirely out 
of the question, and a vast number of local applications had proved 
UDsnccessfuK It occurred to me here, ih^ some benefit mi^t be 
derived from mercurial ointment, gently rubbed over the afiected 
parts, assisting its action by the use of rollei^ applied round the 
joints. Fortunately, ibe experiment proved successful; in the 
course of a week or ten days, the swelKng diminished considerably, 
the pain is nearly gone, and the power of motion is returning^ 
His mouth has become a&cted, but the relief experienced appears 
to be proportioned, not to the influence of mercury on the general 
system, but to its effect on each individual joint. As a proof of 
this, I may state that the man has been mercurialised before, but 
without any favourable result. 

Here, gentlemen, is an important point for consideration. A 
patient labours under a certain number of local inflammations, for 
which mercury is given internally, so as to afiect the mouth, but 
without any manifest improvement of symptoms; we afterwards 
try the same remedy in another form ; we apply it locally, in the 
shape of ointment, rubbed into the skin over the diseased parts, and 
we succeed in giving relief This is a fact deserving of attention. 
Yoii will perhaps ask me to explain this — I cannot do it ; but I cap 



ARTHRITIS. 81 

bring forward many other analogous exannples. If you refer to Mr. 
M'Dovvel's valuable paper on Erysipelas, published in a late number 
of the Dublin Medical and Chemical Journal, you will find that 
many cases of this affection derived great benefit from the use of 
mercurial ointment; in fact, much more than they could by giving 
•mercury internally. In the next place, I have met with many 
cases of enteritis and peritonitis, where the disease continued after 
the system became affected by mercury ; and I have observed that 
these cases yielded rapidly to blistering the abdomen, and dressing 
the raw surfaces with mercurial ointment. Dr. IMarsh and I 
attended a young gentleman lately, who had low fever, accompa- 
nied by a quick but, feeble pulse, and great restlessness. About 
the tenth day, his belly became tender and exquisitely painful ; he 
had thirst, diarrhoea, and other symptoms of enteric and peritoneal 
inflammation. Before his illness, he had been of rather delicate 
habit, and had further impaired his health by close study. He was 
therefore unfit for depletion, and of this we were convinced by the 
debility which followed the application of a few leeches. Under 
these circumstances, we ordered a large blister to be applied to the 
abdomen, and the vesicated surface to be dressed with mercurial 
ointment. This proved eminently successful ; the peritonitis, ente- 
ric irritation, and fever, soon disappeared, and the young gentle- 
man recovered completely. The same thing is seen in many cases 
of pleuritis ; the constitutional effect of mercury will fail in remov- 
ing the affection of the pleura until it is applied locally. I might 
also refer to instances of common inflammation of the testicle, in 
which mercurial ointment, smeared over the part, has been found 
decidedly beneficial. It is unnecessary for me, however, to multi- 
ply examples ; what I have stated give ample proof of the utility 
of mercury applied locally. When I was a student, it was the 
fashion to scout the doctrine that any distinct effect could be pro- 
duced by the local application of mercury ; our teachers laid it 
down as an axiom,, that, to produce any sensible effect, it was 
necessary that it should first enter the system through the lym- 
phatics. Thus, when you rub mercurial ointment over the liver 
to remove hepatic derangement, they said, before it could exert any 
influence on the liver, it had to "pass along the thoracic duct, be- 
come mixed with the circulation, and manifest its peculiar action* 
on the whole economy. Hence, in a case of hepatitis or testitis^it 
was deemed useless to apply mercurial ointment over the liver or 
testicle, since it had, as they expressed it, to go its rounds through 
the whole system, before it could affect either of these organs. 
This reasoning has an appearance of plausibility, but it is contra- 
dicted by facts. Numerous examples might be cited to prove that 
the greatest, advantage may be derived from the local application 
of mercury, independent of any effect produced by it on the general 
system. How often do we see an incipient bubo dispersed by 
mercurial frictions, before any constitutional effects occur? How 
frequently do we see laryngeal and hepatic inflammation relieved 



82 GRAVES'S CLINICAL LECTURES. 

by the use of mercurial ointment without salivation ? Do the bene- 
ficial effects, which we so often observe from the emplastrum 
ammoniaci cum hydrargyro, depend necessarily upon the mouth 
being affected ? Is the relief which follows the use of mercurial 
ointment in erysipelas or testitis, unattainable unless preceded by 
mercurial action in the whole system ? Indeed, any person who 
reviews this subject dispassionately, will see that the doctrine of 
a preliminary constitutional affection being absolutely necessary, 
in order to obtain the specific action of mercury on any par- 
ticular organ, is wholly untenable ; while, on the other hand, there 
is a host of evidence to prove that, locally applied, it produces a 
primary and distinct effect, totally independent of its action on the 
general economy. 

The last case to which I shall direct your attention, is one of 
syphilitic iritis. A young man has been admitted this morning, 
presenting symptoms of secondary syphilis in a well marked form, 
but simple and incomplicated by any previous treatment. He took 
no medicine for the primary or secondary symptoms, except two 
pills, which he got at a dispensary about two months ago, and 
which were not followed by any sensible effect. The secondary 
symptoms came on with pains and feverishness, and are at present 
extensively diffused over his body in the form of elevated blotches, 
of a character intermediate between the papular and squamous. 
About four or five days back, he was advised to take a warm bath 
for his pains, but having to walk a considerable distance afterwards, 
the day also happening to be chilly and sharp, he got cold in re- 
turning home, and soon after experienced pain in the left eye, with 
lachrymation, and diminution of the power of vision. Had he been 
exposed in the same way while in health, he would probably get 
slight conjunctivitis, or sore throat, or bronchitis ; but the case was 
altogether different with a man labouring under a constitutional 
affection, having a tendency to manifest itself in almost every tissue 
of the body, and prepared to modify every form of inflammation to 
which accident might give rise. Again, if the man's constitution 
was in a sound state, his feverish cold, or conjunctivitis, or sore 
throat, could be removed by very simple means, such as bathing 
the feet, taking a little warm whey on going to bed, and some 
opening medicine the next morning. But here the" state of the 
constitution occasions the substitution of syphilitic iritis for simple 
conjunctival inflammation, and demands a peculiar plan of treat- 
ment. You are all aware that persons who have taken mercury 
for syphilis, without being entirely cured, are very liable to get 
iritis on slight exposures. Some persons attribute this entirely to 
the mercury ; but mercury, in such cases, m.erely acts by rendering 
the patient more liable to cold, so that when iritis occurs in a 
patient who has been under a mercurial course, it is not in conse- 
quence of the direct operation of mercury, but by its increasing his 
liability to be affected by impressions from cold. For the same 
reason, the circumstance of his having taken mercury before is 



SYPHILITIC IRITIS. 83 

not, as some persons maintain, any argument against his using it a 
second time. 

On examining this man, we found that he had some pain re- 
ferred to the eyebrow; the eye also is more vascular than natural, 
and presents that appearance which is so characteristic of iritis; 
there is some alteration in the colour of the iris along its free 
margin, but no irregularity of pupil. Along with these symptoms, 
there is dimness of vision, and objects appear as if seen through a 
veil. This arises not from any opacity of the cornea, or opales- 
cence of the aqueous or vitreous humours, but from inflammation 
affecting the iris, cihary zone, and, probably, the coats of the retina. 
In such cases, where the inflammation spreads from the iris to the 
ciliary zone, it would appear that the ciliary nerves and retina par- 
take in the mischief, for vision becomes affected before we can dis- 
cover any appearance of derangement in the optical instrument. 
The peculiar appearance of the eye in this man, the change of 
colour in the free margin of the iris, and the diminution of the 
power of vision co-existing with an eruption of the skin, point out 
the nature of the disease, and show that the affection of the eye, 
though proceeding from a common cold, has been modified by the 
syphilitic taint in the constitution. 

We next come to consider the plan of treatment to bo pursued. 
In order to prepare his system for mercury, I have ordered him to 
be blooded, purged, and put on the use of antimonials for two or 
three days. Venesection, purging, and tartar emetic, may be of 
some use in relieving or arresting the symptoms of iritis, but I do 
not place any great reliance on them for removing the disease ; I 
merely employ them as auxiharies, depending on mercury for the 
cure. Here it may be necessary to observe, that there is conside- 
rable variety in cases of iritis. Some are extremely mild ; there is 
no palpable sign of acute inflammation present, and the chief symp- 
tom is diminution of the power of vision. Such attacks are some- 
times not perceived by the patient until some accident informs him 
that the sight of one eye is nearly gone. In other cases, after 
reaching a certain point, it begins to decline, and frequently termi- 
nates spontaneously. Others present symptoms of a more decided 
character, but still are free from danger. Every attack, however, 
where the inflammation is at all of an intense character, *will go on 
to destroy vision, unless met by prompt and efficacious treatment. 
In this man's case the symptoms are not very acute, and hence 
there is no necessity for having recourse to mercury at once ; the 
disease might certainly terminate in disorganisation of the, eye, but 
it would be some weeks before this would be accomplished. On 
the other hand, there are cases which, if neglected, v/ould destroy 
vision irremediably in the space of three or four days. Such cases 
require extremely prompt and energetic measures. But where 
iritis is not of a violent kind, you need not depart from the plan of 
treatment you would have laid down for the cure of syphilitic 
affections where no iritis existed. Here you bleed, purge, give an- 



84 GRAVES'S CLIXIC.\L LECTURES. 

timonials and mercury, and you find that the syphilitic eruption and 
iritis disappear together. But where the symptoms of iritis are so 
severe as to threaten rapid disorganisation of the ey?, you disregard 
the syphilitic affection, and direct your entire attention to. the pre- 
serva'tion of the eye. Here you bleed, leech, apply belladonna to 
the eve, and give calomel, in doses of ten grains or a scruple, every 
third'or fourth hour, so as to bring the system as rapidly as possible 
under the influence of mercury. 

With respect to belladonna, I believe you are all aware of its value 
in iritis. Some think that its action is merely mechanical, that it 
dilates the pupil and no more; but I am firmly convinced that its 
influence is not limited to mere dilatation of the pupil. I believe 
that it acts on the vitality of the eye, and that Tvhen employed ex- 
ternally or internally, it possesses the properties of diminishing the 
irritability of that organ, and thus tends indirectly to remove local 
inflammation. In scrofulous ophthalmia, where the eye is exqui- 
sitely sensible, where the slightest exposure to light causes intense 
pain, and copious lachrymation, one of the best remedies I am ac- 
quainted with is belladonna, given internally. Thus, you perceive 
that belladonna has not only a mechanical action, producing dila- 
tation of the pupil, and tending to prevent adhesions, but also, by its 
influence on the retina and ciliary nerves, diminishes the irritability 
of the eye, and aids materially in effecting the removal of local 
infiammatioD. 



LECTTTRE VII, 

General remaiks on the pathology of paralysis — Dr. Graves's new views upon this 
subject — Their application to the atadj of several varieties of paraplegia — Expla- 
nation of Mr. Stantef's cases of paraplegia ; of Dr. Stokes's cases — Two cases of 
paraptc^;ia after enteritis — Paraplegia after metritis -^ Paraplegia the consequence of 
poisoning bj lead ; by afsenic — Paraplegia arising from irritation of the urethra 
(case a>mmcmcated by Dr. Hatton). 

Havijcg recently met with some very interesting and remarkable 

cases of impairment of the muscular functions of the lower extre- 
mities, 1 am anxious to offer a few observations on paraplegia, par- 
ticularly while the subject is still fresh in ray mind t we can resume 
the consideration of our clinical cases at a future opportunity. I 
would entreat your favourable attention on this occasion, while I 
lay before you some opinions on paraplegia peculiar to myself, and 
differing from the views entertained bv the generality of medical 
writers: the subject, too, is one of extreme interest, involved in 
much obscurity, and offering an extensive field for investigation : I 
trust, however, I shall be able to communicate some new matter, 
calculated to throw much additional light on the nature of this af- 
fection, and thus contribute to fill up the blanks which exist in an 
important department of pathological medicine. 



PARAPLEGIA. 83 

You are aware that by paraplegia is meant that species of para- 
lysis in which the lower extremities are affected — a paralysis fre- 
quently embracing loss of motion and joss of sensation in the lower 
extremities, accompanied in many instances with derangement of 
the motor power of the bladder and rectum. Now, 1 wish you 
clearly to understand that it is not my intention to describe the 
symptoms, or discuss the causes, of those species of paraplegia 
which are well ascertained, and of which you will find satisfactory 
descriptions in your books : under this head may be classed all 
those cases which are produced by disease of the spinal marrow, 
its membranes, the vertebrae or their appendages, their ligaments, 
and diseases directly affecting the great nerves which supply the 
lower extremities. All these matters have been sufficiently studied, 
and require no additional observations from me ; my object is to 
elucidate some of the obscurer varieties of paraplegia. I have 
touched on this topic before in my lectures delivered at the Meath 
Hospital, but since that time I have met with many cases, and 
made inquiries which tend to throw additional light on the subject, 
I have read, with the attention which it merits, a lecture on this 
subject, published by my colleague. Dr. Stokes, in Renshaw's Lon- 
don Medical and Surgical Journal, and also Mr. Stanley's inte- 
resting cases in the 18th volume of the Medico-Chirurgical Trans- 
actions, published in the year 1833. In Mr. Stanley's paper, several 
cases of paraplegia are brought forward, the explanation of which 
had not been understood before or even at the time he wrote, but 
which I had given several months previously, as applied to para- 
lysis in general, in two lectures in the 58th and 59th numbers of the 
London Medical and^ Surgical Journal, and which had been de- 
livered at the Meath Hospital, in Nov. 1832, and were published 
immediately afterwards. In fact, the explanation offered by Mr. 
Stanley is merely a corollary of the propositions which I laid down 
at that time, and which I shall beg leave to repeat here. 

Before I commenced my investigations on the subject, patholo- 
gists, in endeavouring to ascertain the causes of paralysis, sought 
for the sources of the disease almost solely in the centres of the 
nervous system. They looked for the causes of paralysis in the 
brain or spinal cord, where they supposed it originated either in 
organic or functional derangement of these important organs. In 
the lectures to which I have already referred, I showed that this 
mode of accounting for all forms of paralysis, by referring them to 
original disease of the nervous centres, was in many instances in- 
correct, and proved, I think to the satisfaction of the class and those 
who read the lectures, that a most important and influential cause 
of paralysis had been hitherto nearly overlooked — a cause which, 
commencing its operation on the extremities, and not on the centres 
of the nervous system, might, by a reflex action, produce very re- 
markable effects on distant parts. I brought forward on that occa- 
sion many arguments, facts, and cases, to prove the possibility of 
such an occurrence — to show that it frequently happens that im- 

3 



S6 GRAVES'S CLINICAL LECTURES. 

pressions made on the extremities of the nerves will generate a 
morbid action in them ; that this morbid action will be conveyed 
along their branches and trunks to the spinal cord or brain ; and 
that, continuing its propagation, it may, by a retrograde course, be 
carried thence along the nerves to distant organs, and in this way 
give rise to disease in parts originally intact and healthy. I brought 
forward several instances to prove that, when a certain portion of 
the extreme branches of the nervous tree has suffered an injury, 
the lesion is not confined merely to the part injured, but in many 
instances is propagated back towards the nervous centres ; and 
that, in this way, not only the nervous filaments of the injured 
part may be affected, but also the main trunk of the nerve and 
other branches, or ihat the lesion may reach the. brain or spinal 
cord, and thus produce still more extensive effects on the system. 
What I endeavoured to impress upon the class at that time was, 
that pain, numbness, spasm, and loss of the power of muscular 
motion, may be produced by causes acting on the extremities of the 
nerves ; and that such affections, commencing in the extremities of 
the nerx'es, may be propagated towards their centres so as to be 
finallv confounded with diseases originating in the centres them- 
selves. For a detailed account of my views on this subject, I beg 
leave to refer to the published lectures ; at present I shall content 
myself with recapitulating a few of the facts on which these views 
were grounded. 

If you place your hand in snow or ice-cold water, you will find 
that it is not merely the parts subjected to the influence of cold that 
become numb, and that the diminution of power is not entirely 
limited to the muscles concerned in the peculiar motions of the 
fingers, but extends also to those of the fore-arm, by which the 
principal motions of the hand are performed. * Here the impression 
of cold is found to affect not only the parts immediately exposed to 
it, but' also parts that are quite removed from its influence and 
warmly covered. We see that not only the muscles attached to 
the fingers, but also those of the fore-arm, undergo from this cause 
a temporary paralysis. Now, if a cause of a trifling nature, and 
acting only for a time, can, whan applied to a part, produce loss of 
power in another and more central part, we may infer that the sam^e 
cause acting permanently might produce permanent paralysis of the 
latter. We can, therefore, conceive how in this case the agency 
of cold might travel upwards and reach the muscles of the arm also, 
and thus we should have a change, commencing in the tip of the 
fingers, propagated to parts at a considerable distance from the 
situation of the original lesion. Again, we find that an injury, af- 
fecting one branch of a nerve, will be propagated by a retrograde 
action so as to affect another and distinct branch, as was exempli- 
fied in a case mentioned in my former lectures on paralysis. A 
young lady, having wounded the inside of her ring-finger with a 
blunt needle, observed that she had, in consequence of the injury, a 
considerable degree of numbness, not only in the wounded finger, 



PARAPLEGIA. 87 

but also in the little finger next to it. Here we find that an impres- 
sion made on the nerve of one finger not only affects that finger, 
but also travels backwards so as to operate on the branch given ofi;' 
by the ulnar nerve to supply the little finger — and given off , ob- 
serve, above the place of the wound — so that the phenomena were 
identical with those which would arise from an injury inflicted on 
the branch which supplied both fingers. Within this last month, 
I have had an opportunity of witnessing a very striking fact of this 
nature. A young gentleman, distinguished for the extent of his 
classical and mathematical acquirements, and who had just suc- 
ceeded in obtaining the senior wranglership, swallowed a small but 
angular piece of chicken-bone. It lodged low down in the oeso- 
phagus, and was not pushed, by means of a probang, into the 
stomach until after the lapse of more than an hour. Considerable 
inflammation of the pharynx, OBsophagus, and surrounding tissues, 
was the consequence ; on the third day of his illness he got a vio- 
lent, long continued, and ague-like rigor, which terminated in a 
profuse perspiration, and ushered in a well-marked inflammation of 
the neck of the bladder. In the next place, we find that impres- 
sions affecting the frontal branches of the fifih nerve may, by a 
reflex action, operate on the retina so as to cause blindness. Here 
the morbid actiontravels from the circumference towards the centre, 
and is again reflected towards the circumference so as to affect a 
separate and distinct part. Of this I lately saw a curious and in- 
structive example. A medical student, travelling through Wales 
on the outside of the mail, was exposed for many hours to a keen 
northeasterly wind blowing directly in his face. When he arrived 
at the end of his journey, he found that his vision was impaired, 
and that everything seemed as if he was looking through a gauze 
veil. There was no headache, no symptom of indigestion, to ac- 
count for this evidently slight degree of amaurosis, and yet he was 
recommended to use cupping to the nape of the neck, and strong 
purgatives. When he consulted me, which he did in the course of 
a few days afterwards, I at once saw that there was something un- 
usual in the case, and, after a careful examination, I at length eli- 
cited from him the fact of his having been exposed to the influence 
of the cold wind. It was now apparent that the retina suffered in 
consequence of an impression made on the facial branches of the 
fifth pair. The cure was efl^ected, not by a treatment directed to 
relieve cerebral congestion, but by stimulation of the skin of the 
face, forehead, temples, &c.* 

It is, however, unnecessary to multiply examples to prove the 
truth of the proposition, that disease may conimence in one portion 
of the nervous extremities, and be propagated towards the centre, 

* [I once saw a similar case, in which hemipleg-ia followed the exposure of 
the part affected to a very cold wind in a sleiorh. It was finally cured by stry- 
chnia, which is almost never the case in hemiplegia depending upon cerebral 
causes. — Ed.^ 



as GRAVES'S CUNICAL LECTUKES. 

and hence, by a reflex action, to other and distant parts. Bearing 
this in mind, we can explain why it is that disease commencing in 
one part of the system may produce morbid action in another and 
distinct part, and it certainly appears strange, that, with so many 
striking examples before ihem. pathologists should have so long 
orerlooked this cause, when seeking to explain the nature of many 
forms of paralysis. If certain irritations of the nervous extremities 
in one part of the body are capable of giving rise to a derangement 
in the whole system of voluntary muscles ; if a local affection may 
become the cause of exalting and rendering irregular the functions 
of every muscle in the body ; then, surely, it is not difficult to con- 
ceive that a cause, local as the former, and tending not to exalt but 
to depress the motor function oi the muscles, n:iay likewise affect 
Dot merely the nerves and muscles of the part, but also those of the 
whole body, or of distant organs, giving rise to paralysis. Now, 
pathologists have long recognised the fact that general muscular 
excitement and spasm may arise from the operation of a local irri- 
tation. A man gets a contused wound on his thumb, or one of his 
fingers, and some superficial nerves are injured. In the course of 
a few days be begins to feel a degree of stiffness about the lower 
jaw and muscles of the neck, accompanied by a sense of constric- 
tion about the diaphragm. This increases gradually, all the volon- 
tary muscles are thrown into a state of fixed spasm, and he gets 
tetanus. Here a few trifling branches of the digital nerves are 
injured, the morbid action is conveyed from them along the nerves 
of the arm to the spinal cord and brain, and is thence, by a reflex 
action, propagated all over the body. A wound of the finger causes 
a morbid action in its nerves, and it has been acknowledged by 
pathologists that this, by acting on the brain and spinal cord, may 
give rise to a general morbid action of the muscular system. This 
being the case, there is nothing improbable in supposing that a 
cause affecting any portion of the branches of the nervous tree, and 
which produces effects of a paralytic nature, may likewise react 
backwards towards the nervous centres, and thence by a reflex 
progress may extend its influence to distant parts of the circum- 
ference. 

To give another instance: how often do we see irritation, com- 
mencing in the intestinal mucous membrane, propagated backwards 
towards the brain ? Take the famiHar example of intestinal worms. 
A child labours under worms : here the irritation of the digestive 
mucous surface, whether it be produced by the worms, or by the 
indigestion which accompanies them, is propagated from the sto- 
mach and bowels to the brain, and thence reflected to the volun- 
tary muscles, causing general convulsions. 

Dr. William Siokes details the following case in his lectures. 
" A young woman was admitted into one of the surgical wards of 
the Meaih Hospital, for some injury of a trivial nature, While in 
the hospital, she got feverish symptoms, which were treated with 
purgatives, consisting of calomel, jalap, and the blac^ bottle ^ z. 



PARAPLEGIA. 89 

remedy which deserves the name of coffin bottle, perhaps, better 
than the pectoral mixture so liberally dealt out in our dispensaries 
as a cure for all cases of pulmonary disease. She was violently 
purged, the symptoms of fever subsided, and she was discharged. 
A few days afterwards, her mother applied to have her readmitted, 
and she was brought in again, and placed in one of the medical 
wards. Her state on admission was as follows: — She had fever, 
pain in the head, violent contractions in the fingers, and alternate 
contraction and extension of the wrist and fore-arm. These mus- 
cular spasms were so great, that the strongest man could scarcely 
control the motions of the left fore-arm. In addition to these 
symptoms, she had slight thirst, some diarrhoea, but no abdominal 
tenderness. On this occasion, a double plan of treatment was 
pursued, the therapeutic means being directed to the head, in con- 
sequence of the marked symptoms of local disease of the brain, and. 
to the belly, from the circumstance of abdominal' derangement 
observed in this and her former illness. She died shortly after- 
wards, with violent spasms of the head and fore-arm ; and as she 
had presented all the ordinary symptoms of a local inflammation 
of the opposite side of the brain, we naturally looked there first for 
the seat of disease. After a careful examination, however, no per- 
ceptible trace of disease could be found in the substance of the 
brain, which appeared all throughout remarkably healthy. She 
had all the symptoms which, according to Serres and Foville, would 
indicate disease of the optic thalamus or posterior lobe of the oppo- 
site side, yet we could not find any lesion whatever of its substance, 
after the most careful examination. But on opening the abdomen, 
we found evident marks of disease ; the lower third of the ileum, 
for the length oj six or eight inches, ivas one unbroken sheet of 
recent ulcerations^* This case, gentlemen, you will perceive just 
now, bears very strong on the subject of paraplegia arising from 
enteritis. 

Again : how often do we see convulsions brought on in the same 
way by cutaneous irritation ? A child gets an attack of fever, 
accompanied by general irritability and restlessness. During the 
course of the disease, the lungs become affected, and the medical 
attendant applies a large blister, which is left on for several hours. 
Next day the symptoms of nervous irritation become more violent ; 
the child is perfectly restless, or, if it dozes for a moment, awakes 
screaming, and is finally attacked with general convulsions. Many 
other examples could be brought to support this view of the ques- 
tion, and prove that morbidly increased action of the whole mus- 

* [It was evidently a case of typhoid fever, or dothinenteritis, which was 
masked by the cerelwal symptoms to which the attention of the physician was 
directed. 1 have never seen a case in which the spasms were limited to the 
fore-arm of one side only ; but I once met with one in which the patient, a young 
woman, laboured under severe and general spasms with delirium which closely 
resembled hysteria; this was a latent case of typhoid fever like that mentioned 
by the lecturer. — EdJ] 

8* 



90 GRAVES'S CLINICAL LECTURES. 

cular system may be excited by a cause acting merely on some 
insulated portion of the nervous extremities. 

I think, therefore, that I am borne out by analogies strikingly 
exhibited by numberless examples, in asserting that the circumfer- • 
ence of the nefvous system has been too much neglected by patho- 
logists, in their explanations of the nature and causes of paralytic 
affections. I could give many instances of pains commencing in 
particular parts of the body, and traveling back towards the spine, 
so as to give rise to an affection of that organ, which has been too 
generally looked upon as the result of idiopathic disease. How 
often does this happen in hysteria 1 How often does it happen that 
the organ primarily engaged in hysterical cases becomes, during 
the attacks, acutely painful, and that, as the disease proceeds, the 
pain travels back towards the spine, until at length the spinal cord 
itself becomes affected, and we find acute pain and tenderness over 
some portion of its track ? I am fully persuaded that many modern 
authors, who have ascribed the phenomena of hysteria and other 
affections to spinal irritation, have been* too hasty and indiscrimi- 
nate in their explanations. In the majority of cases, you will find 
hysteric patients complain at first, not of pain in any part of the 
spinal cord, but in the right side in the situation of the liver, in the 
region of the heart or stomach, or in the head, or the pelvic region. 
At this period there is seldom any tenderness over the spinal cord; 
but, as the disease goes on, the irritation which existed in some of 
those situations to w^hich I have referred, is extended to the spine, 
and pain and tenderness are now felt over some of the spinous pro- 
cesses of the vertebrse. When this has taken place, then the spinal 
irritation thus produced becomes itself a new cause of disease, from 
"which, as a centre, the morbid influence is propagated to other 
organs. The profession owe much to Teale, Griffin, and other 
"writers, who have pointed out the importance of attending to this 
spinal tenderness in cases of hysteria, &c. Still, however, like all 
those who have been employed in investigating a new subject, they 
have perhaps generahsed too hastily, and have, in many cases, 
regarded this spinal tenderness as a cause, when it should have 
been merely considered as a consequence. 

Having thus endeavoured to explain some of the general prin- 
ciples which should guide us in the investigation of nervous dis- 
eases, I shall relate some cases of paraplegia, which, though differ- 
ing in their origin as to the organ inflamed, will strike you as 
exhibiting a close analogy to those published by Mr. Stanley. " In 
November, 1832, I atte'nded, with Mr. Kirby and Mr. Cusack, a 
young gentleman, aged fourteen, who was residing at a boarding 
school in the vicinity of Dublin. He had eaten a large quantity of 
nuts on the eve of Allhallows, and had, in consequence, obstruction 
of the bowels, attended with sense of weight and pain of the sto- - 
mach, nausea, loss of appetite, and obstinate constipation. Active 
purgatives, of different kinds, were employed without effect, and 
the obstruction was only removed by the use of repeated enemata, 



PARAPLEGIA. 91 

thrown up with Read's syringe, introduced as far into the cavity of 
the intestine as the circumstances of the case permitted. To these 
means, assisted by leeching and stuping, the constipation yielded; 
but its removal was followed by symptoms of enteric inflammation, 
embracing not one, but all the coats of the intestine — the mucous, 
the muscular, and certainly the peritoneal. The occurrence of a 
new and violent disease greatly impeded his cure ; we had a long 
and anxious attendance, and the young gentleman escaped with 
great difficulty. However, the enteric symptoms at length gave 
way, convalescence became manifestly established, the patient was 
able to sit up in his bed, and as his strength and appetite were 
rapidly returning, he was informed that he might get up. On 
'attempting to leave his bed, it was found that he had lost the power 
of using his lower extremities — in fact, he had become paraplegic. 
He had perfect power over his arms and trunk, but the lower extre- 
mities were quite useless. The paralysis, however, was entirely 
limited to the muscles; there was no diminution of sensibility in 
the limbs ; no numbness, pain, or sensation of formication ; and the 
muscular functions of the bladder and rectum were, apparently, 
uninjured. 

Before I enter on the explanation of this case, permit me to 
recite the following : — In the month of November last, I was 
called to visit a lady residing in the neighbourhood of Merrion 
square, who was said to be labouring under symptoms of dyspepsia. 
She had a sense of weight about the stomach, nausea, tendency to 
vomit, epigastric and hypochondriac tenderness, (the latter situated 
in the right side,) but no fever or excitement of the circulation. In 
the course of two or three days, she became slightly jaundiced, and 
it was evident that the latent cause of her disease was, in all pro- 
bability, a gastro-duodenitis terminating in an affection of the liver. 
It is sufficient to say that this lady's symptoms went on, and that 
the diseased action gradually extended to the whole intestinal tube, 
liver, and peritoneum. Her bowels became tympanitic, her belly 
extremely tender on pressure, she got low fever, with quick pulse 
and great restlessness, and was saved with difficulty by the repeated 
application of leeches, and the use of calomel so as to affect the 
mouth. She, became convalescent; but with the return of health, 
it was found that she had lost the power of using her lower extre- 
mities. She still continues paraplegic. 

In the case of the young gentleman already detailed, you will 
recollect that the paralysis was entirely limited to the muscular 
functions of the lower limbs, and that there was no derangement 
of sensation, no lesion of the muscular powers of the rectum and 
bladder. The same thing occurred in this case. There was in the 
beginning no impairment of sensibility, and the power over the 
rectum and bladder was uninjured. " Within the last three weeks, 
however, she has complained of pain in the loins and bowels, and 
the muscular functions of the bladder are becoming deranged."'* 

* This sentence was inserted on the 23d of March, 1835. Mr. Carmichael 
and Dr. Nalty have seen this lady repeatedly. 



92 GRAVES'S CLIMCAL LECTURES. 

Indeed, the case is rather unfavourable ; it has resisted the ordinary 
reiTiedies, and threatens to become one of confirmed paraplegia. It 
is to be observed, that in this lady the loss of power was much 
more complete than in the young gentleman before referred to; his 
paraplegia was by no means perfect, and yielded to the employment 
of stimulating frictions to the extremities, combined with a cautious 
use of internal stimulants and tonics. In neither of these cases was 
the loss of muscular power so great as to deprive the patients of 
the use of their legs while lying in bed. They could then be raised, 
flexed, and extended with apparent ease and strength ; and yet, 
when the patient attempted to stand up or walk, he was totally 
unable to do either, his legs sinking under him; and even whea 
supported by a person at each side, so as to take the greater part 
of the weight of the body off the Umbs, he was still unable to advance 
one foot before another. I cannot understand why so great a dif- 
ference should exist between the muscular force of the legs in the 
one position and in the other. 

Here, you perceive, we have more or less complete loss of power 
of the lower extremities, supervening on inflammation of the gastro- 
intestinal mucous surface. Of this I have now witnessed several 
examples. How are we to account for this ? In what way does 
paraplegia arise from inflammation of the bowels 1 The mode in 
which I would explain this phenomenon is as follows: — The im- 
pression made by inflammatory derangement on the nervous fila- 
ments distributed to the mucous coat of the intestines is propagated 
to the spinal cord, and from this reacts on the muscular Inunctions 
of the lower extremities. It is true that the intestines, and most of 
the abdominal organs, are almost exclusively supplied with nerves 
from the great sympathetic ; but you are to recollect that these 
communicate by numerous branches with the spinal nerves, and 
that, consequently, morbid impressions made on their extremities 
may be rapidly and extensively propagated to the spinal cord, and 
from thence by a reflex action to the muscular nerves of the lower 
extremities. When I first met with cases of parapleofia after in- 
flammation of the bowels, or fever with gastro-enteric symptoms, I 
thought that, owing to some peculiarity in the case, the great lum- 
bar nerves had become implicated in the disease; that there was 
an actual inflammatory state of the neurilema, accompanied by 
thickening and eff'usion, which, by compressing the nervous matter, 
gave rise to the paraplegic symptoms. A more extensive review 
of the subject, however, has convinced me that this is not the fact ; 
for, if it w^ere, the affection of the nerves would naturally be attended 
with acute pains shooting in the direction of their course — for, as 
far as my experience goes, in every instance of inflammation at- 
tacking the neurilema, intense pain is felt in the parts to which the 
branches of the affected nerve are distributed. Again, though 
this explanation -might apply to cases in which the inflammation 
was general — as where enteric is combined with peritoneal inflam- 
mation — it would not apply to those cases in which the inflam- 



PARAPLEGIA. 93 

matory action is localised. Thus, in Mr. Stanley's cases, the 
paraplegia supervened on inflammation principally limited to the 
kidneys. In seven cases detailed in Mr. Stanley's paper, we find 
paralytic symptoms produced, not by any derangement commencing 
in the brain or spinal cord, but in consequence of an irritation having 
its seat and origin in the kidneys ; and yet, in the majority of his 
patients, the paraplegia was as complete as if it had been produced 
by idiopathic disease of the cord or its' investments. What was 
equally remarkable, many of those cases were accompanied by 
spinal tenderness ; so that the most experienced practitioners, on a 
review of the symptoms, were inchned to look upon them as cases 
of disease affecting the vertebrge, or the spinal cord and its sheath. 
Yet on dissection there was no caries of the bones: no destruction 
of ligaments ; no remarkable vascularity, softening, or suppuration 
of the spinal cord ; no inflammation of its membranes, or eflfu- 
sion into its sheath. In almost all, the morbid phenomena were 
confined to the kidneys ; there were depositions of pus dispersed 
through their substance, and the mucous lining of the infundibula, 
ureters, and bladder, was thickened and vascular. The formation 
of purulent matter was not, however, connected with the paraplegia 
further than as being, like it, produced by the same cause — inflam- 
mation of the kidney. In one case the paraplegia was very com- 
plete, and yet the inflammation of the kidney had not advanced to 
the stage of suppuration. 

There can be little doubt that others have frequently noticed the 
occurrence of paraplegia after inflammation of the bowels, although 
no author has as yet written upon the subject. It is well to be ac- 
quainted with the occasional occurrence of so untoward and obsti- 
nate a sequela of enteric inflammation, in order that we may watch 
attentively the state of the lower extremities immediately after the 
inflammation of the bowels has been subdued. As the patient, in 
such cases, has no pains in his limbs, and is not conscious of any 
loss of power until he attempts to stand up — and as this attempt is 
not usually made for many days after the subsidence of the inflam- 
mation of the bowels, in consequence of the great debility which 
the disease and the active treatment necessarily resorted to produce 
— this variety of paraplegia is very liable to be overlooked in its 
commencement, and is thus neglected at the very period when 
treatment is almost likely to prove beneficial. The foregoing obser- 
vations have, no doubt, excited a suspicion in the minds of some of 
you, that the paralysis so often observed to follow painter's colic 
may be derived from a reaction of the nervous system of the bowels 
on that of the muscular system in general. Dr. Bright, indeed, 
has asserted that inflammation of the spinal marrow or sheath, as 
denoted by spinal tenderness, always precedes the paralysis pro- 
duced by lead. It often does, but by no means constantly ; for I 
have pointed out to you several cases in this hospital in which not 
the slightest vestige of spinal tenderness could be detected either 
before the commencement, or during the progress, of the paralysis 



94 GRAVES'S CLDHCAL LECTUEES, 

which so often follows painters colic. I am not inclined to adopt 
the supposition that the paralysis in such cases is merely secoodaiy, 

and the result of the intestinal irritation. I think it moeb more 
probable that it depends on the poisonous efiects of the lead acting 
directly on the nervous s\-stem. The same obserTation applies to 

the paralysis which so often occurs as a result of large doses of 
arsenic. Orfila has remarked that some of the dogs he experi- 
mented on, and which narrowly escaped dying io conseqaence of 
large dcses of arsenic, became, when they recovered Irora the imme- 
diate effects of the poison, permanently paraplegic I look apoD 
this paralysis as a direct consequence of the deleterious acti€>o of 
arsenic on the nervous system, and not as the resak of the gastro- 
enteritis it invariably produces. The fact, however, is well worthy 
of attention, that both arsenic and lead produce intestinal irritation 
in the first instance, and loss of muscular power in the second. A 
knowledge of this fact will prepare us for understanding the cob- 
nection which appears to exist between intestinal irritatioa and 
paralysis. 

In a lecture published by my colleague. Dr. William Stokes, in 
the 137th number of the London Medioil and Sigrgiad Mmrmal, 
he makes the following observations, which I shall h^ leaie to 
quote: — '• Here, then, we have well-marked paraplesia without any 
perceptible organic change in the spinai cord or its investments, bat 
presenting distinct traces of disease in the kidneys. This leads me 
to observe the very close connection which exist between the* kid- 
neys and spinai cord — a connection which has been long recognised 
by medical practitioners, but only in a limited point of view: for, 
though they were of opinion that disease of the kidneys and a dis- 
charge of ammoniacal urine were the results of spinal disease, 
they never seem to have reflected that the reverse of this might 
happen. It seems, however, now to be almost completely esta- 
blished, that disease of the kidneys may produce symptoms which 
are referable to disease of the spine. Medical men have been too 
much in the habit of looking at this matter only in one point of 
view. They know that disease of the spine will produce disease of 
the kidneys, and here they stop; but it has been shown that the 
reverse of this may happen, and that renal disease may produce 
very remarkable lesions in the functions of the spine. CM" this verv' 
curious occurrence we have many analogies in pathology. Thus, 
for instance, in several cases of cerebral disease, but particularly in 
hydrocephalus, we have vomiting: here we have functional disease 
of the stomach depending on disease of the brain. Take the reverse 
of this, — observe the delirium which attends a case of gastro-ente- 
ritis; here you have the functions of the brain deranged in a most 
remarkable manner, and this produced by sympathy with an in- 
flamed mucous membrane. The truth is, that in the spine and 
kidney, as well as in various parts of the body, we may have two 
organs so closely connected in sympathy, that disease of the one 
will bring on serious functional lesion of the other." 



PARAPLEGIA. ' 95 

It will be seen that these observations coincide, in many points, 
with the principles I have laid down in the published lectures 
which I delivered on the subject of nervous pathology, and to 
which I have already referred. On this point Mr. Stanley makes 
the following remarks : — "In reflecting on the phenomena of the 
first series of cases which have been detailed in this paper, it might 
be thought improbable that irritation, commencing in the kidney or 
in the bladder, should be propagated through sentient nerves to the 
spinal cord, and that the impression should thence be transmitted 
through both the motive and sentient spinal nerves to the limbs — 
here occasioning an impairment both of sensation and of the power 
of motion. Some illustration of this subject seems to be furnished 
by the researches of experimental physiology. If, in an animal, " a 
few seconds after it has been deprived of life, the spinal cord be 
then divided in the middle of the neck, and again in the middle of 
the back, upon irritating a sentient organ connected with either 
isolated segment, muscular action is produced — that is to say, a 
sentient organ is excited — and an irritation is propagated through 
the sentient nerve to the isolated segment of the spinal marrow, 
where it gives rise to some change, which is followed by an impulse 
along the voluntary nerves to the muscles of the part."* In the 
instances which have been adduced, irritation, commencing in the 
nerves of an internal organ — the kidney — has been transmitted 
through the spinal cord to the motive and sentient nerves of the 
lower extremities; but the same phenomena may occur in an oppo- 
site order, as in the case of a compound fracture or other severe 
injury of the lower extremity, followed by retention of urine from 
irritation arising in the anterior crural and ischiatic nerves, and 
communicated through the lumbar and sacral plexuses of spinal 
nerves to the nerves of the bladder. Extending these views to 
cases of neuralgia where there is no visible derangement of struc- 
ture or other local cause of excitement, it will always be difficult 
to determine whether the source of irritation be in the affected 
nerves, or in the central portion of the nervous system whence they 
are derived." 

You will perceive that this explanation, as far as it goes, though 
not in the same words, is in meaning the same as that which I 
h.ave given, with this exception — that it is only a corollary of the 
general principles which I had laid down in my lectures on the 
pathology of the nervous system. Long before the publication of 
Mr. Stanley's paper, I had established the proposition that impres- 
sions made upon any portion of the nervous extremities may be 
propagated towards their centres, and thence by a reflex action 
transmitted to the nerves of other and distant parts, so as to give 
rise to morbid phenomena analogous to those which are produced 
by disease originating in the central parts themselves. Applying 
this principle to the subject of paraplegia, we shall find that, inde- 

* Outlines of Human Physiology, by H. Mayo. 



06 GRAVES'S CLINICAL LECTURES. 

pendently of cerebral or spinal disease, it may arise from a variety 
of causes, each referable to lesions commencing in distinct and iso- 
lated portions of tiie nervous extremities. Thus, in Mr. Stanley's 
cases, the exciting cause seems to have originated in the urinary 
system ; in the cases which I have detailed, where it supervened 
on inflammation of the bowels, it commenced in the digestive (and 
it appears, from a communication made to Mr. Stanley by Mr. Hunt, 
of Dartmouth, that the same thing may result froni irritation exist- 
ing in the uterine) system. Mr. Hunt alludes to several cases of 
disease of the uterus being followed by such loss of power in the 
lower limbs, that the patients were entirely confined to bed ; adding 
that there was no change of structure in the parts to which the 
symptoms referred as the source of irritation. In addition to these, 
I shall in my next lecture bring forward several cases to prove that 
a similar loss of power may be produced by the action of cold on 
the lower extremities. Indeed, the number of cases which I have 
recently met with, where paraplegia was evidently brought on by 
exposing the lower extremities to cold and wet, has very strongly 
directed my attention to this form of the disease; and I trust I shall 
be able, at our next meeting, to communicate some'very interesting 
matter on the subject. 

I shall conclude this ^lecture by reading the following case, for 
which I have been indebted to the kindness of my friend Dr. 
Hutton. 

" Richard M'Nab, a sailor, aged thirty-eight, was admitted into 
the Richmond Hospital on the 16th of January, 1835, and placed 
under 'Dr. Hutton's care. His previous history was briefly as 
follows: — In the summer of 1826 he strained his back in leaping- 
and was confined to bed in consequence of the accident, but reco- 
vered in about twelve days. Shortly afterwards he contracted 
gonorrhoea, which was attended with hernia humoralis ; this yielded 
to repeated local bleeding, but a gleet remained, and this, after con- 
tinuing for some time, disappeared under the use of sea-bathing. 
He then enjoyed good health, with the exception of occasional 
slight pain in the lumbar region, until October, 1830, W'hen, being 
much exposed to cold and wet during a long and fatiguing voyage, 
he got an attack of piles, for which he was under medical treat- 
ment for seven months. During the continuance of this affection, 
he first observed a frequency in micturition, but had no retention 
or sensible obstruction of urine. After recovering from the hemor- 
rhoidal attack, he enjoyed good health until September, 1834, when, 
coming from Cadiz to the port of Dublin in a very leaky vessel, he 
sufl^ered greatly from cold, wet, and fatigue — being almost con- 
stantly engaged at the pumps, w^hich could not be left for ten 
minutes at a time. In addition to this, being deprived of his usual 
allowance of spirits for thirty-two days, he found himself, on his 
arrival in Dublin, in a very weak state. He rested from his occu- 
pation for a fortnight after discharging his cargo, and states that 
during this time he drank from four to six glasses of whiskey daily. 



PARAPLEGIA. 97 

He then went on board the Elizabeth, of London, as chief mate, 
but after eight or nine days his back and lower extremities became 
affected with pain and weakness, which increased to such a degree 
that he was obliged to give up his occupation on the thirteenth day. 
He states that, during the time his back and legs were getting weak, 
he was obliged to pass water about three times in an hour, which 
he did with pain and tenesmus. On the 1st of January the pain 
of his back was very severe, and he lost the use of his limbs, but 
not completely, for he could support himself, and even walk a little 
with the aid of two sticks. 

, *' At the time of his admission he appeared somewhat broken 
down in his general health ; he was pale, emaciated, and laboured 
under derangement of his digestive organs. He sufl^ered from 
occasional chills, succeeded by heats and sweating, which occurred 
at irregular .periods ; he also laboured under micturition, dysuria, 
and the stream of urine was much diminished; the weakness and 
loss of power in his lower extremities as reported. 

" His treatment was as follows : - — First, cupping over the loins, 
then moxse in the same situation; attention tohis digestive organs ; 
diluents and opiates for the urethral symptoms. On the 20th of 
the same month, a very close stricture was found to exist in the 
membranous portion of the urethra. A small catgut bougie of 
double length was introduced, so that one-half of it projected from 
the meatus; over this was slided a smjall gum-elastic catheter of" 
ordinary length, and open at each end, until it traversed the stric- 
ture and reached the bladder ; the catgut bougie was th"en with- 
drawn, and the gum-elastic catheter secured. A little constitutional 
disturbance followed, but soon subsided, and in a few days gum- 
elastic catheters of a much increased size were introduced with 
■facility. 

"A very remarhahle amendment took place in his hack and 
lower extremities, in a very few days after the first introduction 
of the instrument ; in fact it was ahnost sudden. Warm baths, 
friction to his limbs, &c., completed his cure. He was discharged 
on the 25th of February, at which time the power of his lower 
limbs was perfectly restored, and the symptoms afl^ecting the urinary 
system had disappeared." 

You at once perceive the extreme importance of this case ; it 
bears directly on the question before us, and proves that urethral 
irritation may, as well as inflammation of the kidneys, give rise to 
paraplegia ; and it affords another striking illustration of the gene- 
ral proposition which I have laid down. 



GRAVES'S CLINICAL LECTURES. 



LECTURE VIII. 



In my last lecture, I gave a brief summary of the opinions which 
I had published on the subject of nervous pathology, in the year 
1833, and showed that the principles there laid down were entitled 
to serious consideration, as connected with the explanation of many 
forms of paralysis hitherto not well understood. I trust I have 
proved to your satisfaction, that the nervous extremities have been 
too much oV"erlooked by medical writers in seeking to explain the 
source and origin of paralytic affections ; and that many cases of 
Joss of the power of motion and sensation can be clearly traced to the 
agency of causes acting primarily on tlie sentient extremities of the 
nervous system. I adduced numerous facts to show, that an impres- 
sion made upon some portion of the extremities of the nerves may 
be propagated towards their centres, and transmitted thence to other 
and distant parts, producing there pain, spasm, impairment of sen- 
sibility, and diminution or total loss of muscular power. With 
reference to the subject of paraplegia, I cited the cases published 
by Mr. Stanley, and expressed my opinion, that the loss of power 
in the lower extremities was the result of a morbid action com- 
mencing in the sentient nerves of the kidneys, and propagated 
through the medium of the spinal cord to the muscular and sentient 
nerves of the lower limbs ; and I brought forward some new cases 
of paraplegia, supervening on inflammation of the bowels, with the 
view of illustrating the principles I had already laid down. 

In the next class of cases we have to consider, the cause of the 
paraplegia is extremely obscure — I mean those cases in which the 
paraplegia occurs during the course of fever. Here the other suf- 
ferings of the patient, and his general debility, attract our notice so 
exclusively, that the paralysis entirely escapes notice until conva- 
lescence is established — until, in fact, the patient wishes to support 
himself on his legs. He then finds, much to his surprise, that his 
limbs collapse under him, and that he has little or no power over 
them ; this appears to him the more extraordinary on account of 
his having recovered a good deal of strength in his upper extre- 
mities. Thus, a Miss F. was attacked in fever, while on a visit to 
a friend in Dublin. She was attended by Mr. Carmichael. Her 
fever was protracted and severe, and exhibited during its progress 
well-marked symptoms of gastro-intestinal irritation and congestion, 
viz., tympanitis, epigastric and abdominal tenderness, &c. When 
her convalescence was established, her attendants found, to theif 
great alarm, that she had no power in her legs. She complained 
of coldness and numbness in her lower extremities. This lady 
gradually recovered the use of her legs, but not until moxse, with- 
out number, had been applied along the course of the spinal 
column. The cure lasted about a year. No evidence could at 



PARAPLEGIA. 99 

any time be detected, indicating disease of the spinal bones or liga- 
ments. Mr. Carmichael has seen several cases of paraplegia fol- 
lowing the remittent gastric fever of children, totally unconnected 
with spinal disease. Such an occurrence is most usual in children 
of a scrofulous temperament, and is seldom, very seldom, remedied 
either by time or medicine. Two explanations suggest themselves 
as capable of accounting for the paraplegia after fever. The first 
rests upon the frequency of the occurrence of violent pain in the 
small of the back in the commencement of this disease. This pain 
in the back is often excruciating, and generally accompanied by 
proportionally violent pains in the lower extremities. I am quite 
as anxious to relieve the pain in the back, in the beginning of fever, 
as I am to remove headache; one is almost as serious as the other, 
for the vital importance of the spinal marrow in the economy is 
scarcely less than that of the brain.* 

In reference to this point of practice, I have been in the habit of 
using the expression, (in order to fix the attention of my pupils) 
that such a patient has not any pain in his head, hut he has gotten 
his headache in the small of his back. Now, when headache is 
the prominent feature in the first stage of fever, how few will omit 
bleeding, leeching, cupping, cold or hot applications, &c., &c.. 
When, on the contrary, the lumbar spinal marrow is the seat of 
the congestion, how generally do practitioners neglect the applica- 
tion of topical bleeding, and otPier appropriate remedies. Were such 
neglect of less frequent occurrence, it is probable that paraplegia 
after fever would not so often be met with. vSome may be inclined 
to look for the source of the paraplegia which follows fever in the 
irritation of the gastro-intestinal mucous surface, propagated by a 
reflex progress of the spinal marrow. It is not easy to decide be- 
tween these two explanations, but I confess myself more inclined 
to adopt the former than the latter. 

I shall now proceed to lay before you some facts and cases illus- 
trating the nature of another form of paraplegia, a form of extreme 
interest, from the circumstance of its being hitherto but ittle under- 
stood, and not mentioned by any writer I am acquainted with, as 
well as from the peculiar nature of its origin, and the frequency of 

* [This form of paraplegia is much less common in this country after con- 
tinued than after remittent or intermittent fever. It sometimes occurs during 
the course of the acute disease, but much more frequently in the chronic cases 
in which repeated relapses have occurred. I met with one case in which the 
disease was speedily fatal: no examination could be made. In several other 
cases the disease was extremely protracted, and was always very difficult to 
remove entirely. It is most probable that no organic lesion exists, although it is 
' not yet susceptible of rigid demonstration. 

The most successful treatment consists in rest, repeated applications of cups 
to the spine, and mild purgatives during the periods of the disease in which 
there is often considerable febrile excitement, and afterwards moxas. The 
treatment therefore is essentially the same as that of inflammatory affections of 
the medulla spinalis. In addition to these remedies, there are many others which 
are more or less beneficial in the late or non-inflammatory stages of the disease ; 
such as strychnia, electricity, &c. — Ed.] 



100 GRAVES'S CLINICAL LECTURES. 

its occurrence. I have, within a comparatively short period of 
time, met with several instances of this affection, and have some 
cases of it at present under treatment. 

Befoj'e I enter on this part of the subject, I may be allowed to 
remark that, in some cases, loss of the power of motion in a limb 
can evidently be traced to the operation of a cause whose action is 
confined altogether to the surface. Thus, in the case of a w-oman 
in Sir P. Dun's Hospital, erysipelas occupied the calf and inside of 
the right leg, and occasioned some inflammation and tenderness 
along the chain of lym.phatics extending to the groin, where one of 
the inguinal glands was slightly enlarged and painful. The erysi- 
pelas yielded to the employment of local and general remedies; 
but, for several days, and particularly while the disease was at its 
acme, she was altogether destitute of any power of motion in the 
affected limb ; she could neither bend the leg on the thigh, nor 
could she raise the whole limb. This affection must have been pro- 
duced by a reflex action propagated from the cutaneous branches to 
the larger muscular nerves. It is evident, that the muscles which 
move the leg on the thigh could have been affected only in this way, 
for they lay far above the part in which the erysipelatous inflam- 
mation existed. It is in the same way that we are to account for 
the paralysis observed in cases of phlegmasia dolens: 

Sometimes the reverse of this happens, and a single limb becomes 
paralysed, on account of an injury done to one of its principal nerves 
by the application of sudden violence, or of pressure long continued. 
Thus, a case was related to my friend Dr. Brennan and myself, in 
which a robust gentleman, having been much fatigued during the 
day, fell asleep after dinner, his head resting on his arms, which 
wxre crossed on the table. In consequence of some unfortunate 
awkwardness in his position, one of the ulnar nerves was com- 
pressed during the time he slept, and, on awaking, his fore-arm and 
hand were completely powerless. Many remedies were tried in 
this case without success, and the paralysis continued until the day 
of his death, which occurred several years afterwards. A lady, not 
long since, was tripped in walking across the floor, and fell with 
considerable force. The parts which sustained the principal shock 
were the left hip and trochanter. From the moment of the acci- 
dent, she lost all power in the left lower extremity, which remained 
permanently paralytic. Fracture or dislocation was suspected at 
first, but a minute and careful examination showed that the suspi- 
cion was groundless. No injury of the spine could be detected, 
and she had no numbness, pain, or formication, in the affected limb. 
After a month, she was placed under the judicious care of Mr. 
Kirby, who used every topical application likely to prove useful, . 
but without the slightest benefit. She returned to the country, 
where she died shortly afterwards, quite unexpectedly, in the bloom 
of life, and without the occurrence of a single symptom indicative 
of approaching danger. No autopsy was permitted. 

I shall now, with the view of illustrating the form of paraplegia 



PARAPLEGIA. 101 

to which I have alluded, read the following very remarkable case, 
which I had an opportunity of tracing through all its stages, and 
which made a very considerable impression on me at the time. 
The history is chiefly derived from notes furnished by the patient 
himself before he became too weak to write ; what relates to the 
latter stages of bis complaint is taken from my own case-book. 

Mr. B., aged twenty-three, was remarkably strong and healthy, 
though of a spare habit. He was able to take a great deal of exer- 
cise, capable of enduring much fatigue, and passionately fond of 
hunting, fishing, and ^hooting, particularly the latter; and, in pur- 
suit of his favourite amusements, frequently exposed himself to wet 
feet during his excursions through bog lands, and when wading in 
the water. These habits, however, he laid aside after the occur- 
rence of the first attack of his illness, which happened in 1829. He 
had for many years been of a costive habit, his bowels being fre- 
quently confined for a week at a time, but did not experience any 
sensible bad effects from this circumstance, and never took any 
aperient medicine. Since the first attack, in January, 1829, this 
state ceased, and his bowels became ever afterwards inclined to 
looseness, which always increased before the appearance of one of 
the attacks, accompanied by griping, nausea, and inclination to 
vomit. Each attack was generally preceded by a copious secretion 
of insipid watery fluid in the mouth, and then the characteristic 
symptoms of his disease commenced. These consisted in obstinate 
and protracted nausea and vomiting; he first threw up whatever 
happened to be on his stomach at the time, and afterwards every- 
thing he swallowed, whether solid or liquid. The matter ejected 
was at first acid and afterwards bitter, varying in colour from mu- 
cous to bilious, but being generally of a greenish and occasionally 
of a bluish tinge. The greenish fluid annoyed him much from its 
extreme bitterness, and the quantity thrown up in the course of a 
day varied from three to four quarts of fluid. He complained also 
of pain, referred to the stomach or lower part of the chest, which 
continued throughout the attack, being most acute at its com- 
mencement; for the last year, this sensation had passed into a feel- 
ing of painful constriction, which he described as a " contracted 
feeling of his inside," and compared it to something like the effects 
of a cord drawn tightly, so as to compress or strangulate his body 
exactly along the outline occupied by the insertions of the dia- 
-phragm. Diiring the prevalence of the attack, he had profuse perspi- 
rations, particularly towards the termination of each paroxysm. 
The duration of the first attack did not exceed four or five days, 
after which, he became quite well, and continued so for six or 
seven months, when his symptoms suddenly returned. He. began 
to reject everything from his stomach as before, but in the course 
of a few days the vomiting disappeared, and for a considerable 
interval he had no return of his complaint. In the year 1830, he 
had three attacks of a similar description ; from these he recovered 
also completely, and without remarking any diminution of power 

9* 



102 GRAVES'S CLIXICAL LECTURESw 

in his lower extremities. Jo 1831, howerer, the disease b^an to 
assume a more serious aspect; the paroxysms became much in- 
creased io seventy, lasted longer, and recurred at shorter intervals. 
For one of these attacks he took mercury and was sativ^ted. In 
1832, his symptoms became still more liolent, and the duration ai 
the paroxysms more protracted. He had one in March, a second 
in May, acd a third in June, each of which was accompanied by 
some Domboess and lo^ of power in the lower extremities; this,' 
however, was slight, and disappeared altogether as the vomiting 
subsided. About this time, he noticed that his urine was scanty, 
and deposited more sediment than usually. He also complained of 
being very apt to catch cold whenever he got out of bed, and stated 
that he soflfered occasionally from severe twitches and paiifs in bis 
legs, thighs, arms, and other parts of hb body, which were generi 
succeeded, and carried oflT, by profuse perspirations. 

Id Aflgusl, 1832, he had a violent attack, which lasted near.- ? 
mooih. The vomiting was incessant, continuing night and c 
and he su^red severely from the feeling of painful constric . 
already described. On getting up after this attack, his l^s s. i- 
denly failed him, and he dropped down on the floor quite poweritss 
The paralysis did not now disappear during the intervals, althc jr 
it grew somewhat better after each fit of vomiting had ceased : 
deed he osed to improve in his walking after the paroxysm : 
entirely disappeared; and, aided by two sticks, supported hiojse 
so as to give some hopes of a recovery, until a recurrence of 
attack reduced him again to a state of almost total parapler 3 
His legs now b^an to waste sensibly, and he noticed that the}' 
lost their feeling and were remarkably cold- He also compla: ^ 
of severe twitches of pain in various parts of his body, accompar. e 
by profuse night sweats, and turbid, scanty urine. 

For some months before his death be was completely parapler 
and continued to be attacked with violent fits of vomiting, i z 
vomiting went on night and day, and he was unable to retain i 
oiildest and most soothing sub^ances for a moment on his stom^ : 
Mr. Crampton and Dr. Irdand attended him with me, and we 
recourse to everything we could think of to allay the irritat 
of his stomach, but in vain. After continuing to resist ol»tine:r 
every form of treatment for five or six days and nights, the von.. - 
ing would suddenly cease, the gentleman would exclaim, " ]Now I 
am well," and he would then eat, with perfect impunity, substances 
which would prove irritating and indigestible to many stomachs. 
This was one of the most singular circumstances I ever witnessed. 
The traDsition from a state of deadly nausea and obstinate retching 
to a sharp feeling of hunger, used to occur quite suddenly. One 
hour he was the most miserable object you could behold, racked 
with painful constrictions acro^ the epigastrium, alternately fleshed 
or bathed with cold perspiration, and rejecting everythii^ from his 
stomach, the next found him eating with a voracious appetite what- 



PARAPLEGIA. • 103 

» 
ever he could lay hold of, and digesting everything with apparent 
facility. 

It may be observed that as the disease in this case proceeded, the 
intervals between the attacks became diminished, while the parox- 
ysms became increased in duration. For the first two years they 
continued only for four or five days, and appeared at intervals of 
six or seven months ; latterly they used to last for eight or ten days, 
and returned every third or fourth week. During the paroxysm 
the only thing which he took was a little cold water with some 
brandy and a few drops of laudanum, which remained longer on 
his stomach than anything else, and enabled him to enjoy a few 
minutes' sleep. He never complained of any headache, and his 
intellect was remarkably clear, and his memory good. 

No trace of organic disease could be detected in the abdominal 
viscera, and there was not the slightest tenderness over any part 
of the spine. He also retained to the last a complete power over 
the bladder and rectum. 

At length his system began to give way ; long confinement to 
bed, and the frequent recurrence of these exhausting attacks, com- 
pletely wore him out, and he sank on the 30th September, 1833. 
A post mortem examination was allowed by his friends, and we 
scrutinized every part of his system with the most anxious care. 
The brain, cerebellum, spinal cord, and their investing membranes, 
were carefully inspected : we examined the large nervous trunks 
that supply the lower extremities, inspected the viscera of the 
thorax, and searched for evidences of disease in the stomach and 
intestinal tube: we could find none. There was no lesion of the 
brain or spinal cord, no thickening or vascularity of membranes, 
the large nerves exhibited their normal condition, the stomach was 
perfectly healthy, the intestinal canal natural, the liver and other 
glandular viscera of the abdomen without any trace of appreciable 
derangement. 

Here, then, was a case of perfect paraplegia, (I say perfect, for 
he had lost all power of his lower extremities for more than two 
months before his death) which may be fairly termed functional, 
inasmuch as there was no lesion of any part of the nervous cen- 
tres to explain the phenomena present. How then are we to 
account for them ? The first symptoms were undoubtedly those of 
abdominal irritation, as manifested by the tendency to diarrhoea in 
an originally costive habit, accompanied by violent paroxysms of 
vomiting, which recurred at distant intervals. Are we to attribute 
this diseased condition of the stomach and bowels, which, from the 
remarkable periodicity of its occurrence, was evidently functional, 
to irritation, congestion, or inflammation of the brain or spinal 
marrow] From the data we are in possession of, it appears that 
this question must be answered in the negative. There was no 
headache, heat of scalp, throbbing of the temporal arteries, or other 
sign of determination to the head; or congestion, or inflammation 
of the brain, either before or during the attacks. The patient's in- 



104 GRAVES'S CLINICAL LECTURES. 

tellect was all throughout rejnarkably clear, and his memtDry good. 

Again, if we look for the origin of the disease in the spinal cord 
or its investments, we can find nothing to assist in explaining the 
phenomena. There was no pain in any portion of the spinal cord, 
and at no period of his illness could we detect any tenderness over 
the spinous processes. The history of the case seems to prove 
that whatever was the cause which operated on the nerves of the 
stomnch and intestines, it gradually extended the sphere of its 
morbid influence to the spinal cord, and, through it, implicated the 
nerves of the lower extremities. The case is in many respects 
highly interesting, and well worthy of the attention of the patho- 
logical inquirer. The dissection was conducted, in the presence 
of Dr. Ireland and myself, by my friend and former ptipii, Mr. 
Harris, so advantageously known for his skill in morbid anatomy. 
It was not made in a hurried or careless manner, each organ was 
carefully examined, and the process occupied at least four hours. 

The next case to which I shall call your attention is one which 
I have already given in a former lecture: it seems, however, to be 
so similar in the nature of its exciting cause to the foregoing, though 
differing in some of its symptoms, that 1 shall beg leave to repeat it 
here. 

James Moore, aged 32, was admitted into the iMeath Hospital on 
the third of March, 1833, under Dr. Stokes's care, for an attack of 
paraplegia, which he attributed to cold and wet feet while engaged 
in working in a quarry. About a month before admission he per- 
ceived a stiffness of the great toe of his right foot, afterwards nunab- 
ness and coldness of the sole, and then of the leg as far as the 
knee, and dragging of the linib in walking. During the progres- 
sion of the disease up along the thigh it commenced in the left foot, 
and, after a few days, he experienced almost complete 'paralysis of 
sensation in the right lower extremity, and a lesser degree in the 
left, accompanied by so much diminuiion of the power of motion, 
as to render him unable to walk without support. About three 
weeks after the appearance of paralysis in the lower extremities, 
the little finger of the right hand was attacked with numbness, 
which passed successively to the rest, attended by some loss of the 
sense of touch and power of grasping objects. He had also reten- 
tion of urine, and the bowels were obstinately constipated. There 
was no tenderness over any part of the spine. He had no pain in 
the head; his pupils were natural; pulse^ sleep, and appetite also 
natural. 

Here we have an instance of paraplegia apparently originating 
from an impression made on the nerves of the lower extremities. 
The man had been engaged in draining a quarry, and during his 
occupation was constantly exposed to wet; shortly after this he 
begins to complain of numbness and loss "of power in the right 
lower extreinity, and during the progression of the disease up 
along the limb, the left becomes similarly engaged. About three 
weeks afterwards, the hands, which had been aUo, but not so fre* 



PARAPLEGIA. 105 

quently, exposed to the influence of cold and wet, begin to be 
afTected with numbness, and the power of grasping objects becomes 
diminished. To what can we attribute tliese symptoms, except to 
the influence of cold acting on the nervous filaments of the 
cutaneous surface of the limbs, extending its morbid impression to 
the spine, and thence reacting on the nerves, so as to produce im- 
pairment of the power of motion and diminished sensation ? The 
man certainly had no symptom of cerebral or spinal disease, nor 
was there anything connected with the state of the nervous cen- 
tres which would lead to the supposition that paraplegia was the 
result of an irritation originally affecting the brain or spinal cord. 
It was on these grounds that 1 gave it as my opinion at the time, 
that the disease was an example of creeping paralysis, having its 
origin in an affection of the peripheral extremities of the nerves. 

The next case is one which was also under treatment in the 
Meath Hospital during the course of last winter : for the particulars 
I am indebted to my colleague, Dr. William Stokes. 

A robust, middle-aged man was admitted into the chronic ward 
of the Meath Hospital, in the latter end of February, 1834, labour- 
ing under paraplegia. He stated that he was generally employed 
as a boatman about the river and port, was frequently exposed to 
cold and wet, particularly in his lower extremities, and that he was 
in the habit of drinking freely. He had enjoyed good health until 
about seven weeks before admission, when he was seized with 
numbness of the feet and legs, which, after continuing for three or 
four days, was followed by tingling pains running along the course 
of the nerves. He then remarked that the power of his lower ex- 
tremities became much diminished, and this gradually increased so 
as to prevent him from walking or even standing without support. 
His bowels became obstinately costive, and about a month after the 
commencement of his attack, he perceived that his urine was dis- 
charged in smaller quantity than usual, and that he was much 
more frequently called on to pass it than before. He also men- 
tioned that he had gonorrhoea about six months before, and that he 
had used balsam copaiba and injections. Some time after this he said 
he noticed some white matter passing with the urine, but did not pay 
any particular attention to it as it gave him no inconvenience. 
His appetite was tolerably good, and he had no headache or any 
symptom of determination of blood to the brain. He denied having 
received any injury of the back, and there was no tenderness over 
the spinous processes of the vertebrae. He had no pain in the spine, 
either before or since the occurrence of his illness, nor was there 
any symptom of inflammation of the substance or membranes of the 
spinal cord. When admitted, he had considerable diminution of 
sensation and complete loss of motion in one of the lower extremi- 
ties ; in the other he still retained some power. He had also reten- 
tion of urine, requiring the daily use of the catheter. 

The treatment was as follows: -;- He was placed on one of Dr. 
Arnott's hydrostatic beds, as there was a great tendency to stripping 



106 GRAVES'S CLINICAL LECTURES. 

over the hips &nd sacrum, a purgative pill was administered two or 
three times a day to remove the costiveness, and he was ordered to 
be cupped over the loins. The latter was done in consequence of 
his complaining of some tenderness on pressure in the situation of 
the kidneys. His symptoms, however, went on without any im- 
provement, and he died about a month after his admission. 

On dissection the following phenomena were observed. The 
kidneys (which were first examined) appeared rather soft, and of a 
yellowish colour, but there was no vascularity, suppuration, or 
other change of structure. The ureters were somewhat distended, 
but presented no other trace of disease. The bladder was contract- 
ed, its muscular coat thickened, and its mucous membrane very 
vascular. There was no affection of the prostate. On examining 
the spinal cord Dr. Stokes observed that he thought the cauda 
equina appeared to be slightly softened, but remarked that from its 
appearance he could hot state that it was actually diseased. The 
rest of the spinal cord appeared healthy and normal ; there was no 
vascularity, effusion, or softening. External to the sheath of the 
cord there was a small, flattened, oval body, about the size of half 
a very small hazelnut, and of a consistence intermediate between 
lymph and' fat. Around this there was some slight degree of vas- 
cularity. Dr. Stokes observed, that from the small size of this body, 
and the peculiarity of its texture, he entertained strong doubts as to 
its having any influence in the production of the symptoms noticed 
during lite. He remarked, although it might have been originally 
the product of inflammation, and have existed in the form of an 
eflTusion of lymph, still the circumstance of its conversion into a 
fatty substance proved that it must have existed for a very con- 
siderable time, and the smallness of its size, as well as the obscurity 
of its origin, did not by any means satisfactorily explain the occur- 
rence of paraplegic symptoms. 

The next case which I have to lay before you, appears to be ana- 
logous in its modeof origin to the former : — "A gentleman of strong 
constitution, and extremely fond of field sports, particularly fishing 
and shooting, exposed himself repeatedly to wet feet at a titne when 
he was labouring under the effects of a long mercurial course. 
Taking large quantities of blue pill, and exposing the lower ex- 
tremities to wet at the same time, are circumstances which have an 
obvious tendency to produce disease, and it is not to be wondered 
if this gentleman became the victim of his want of caution. He 
got numbness and weakness in his legs, which he at first attributed 
to fatigue and over exertion ; but as the disease went on, he became 
more and more powerless, and, finally, applied to me respecting 
his illness. On examination I found that- he had no pain in the 
back, or tenderness on pressure ; nothing, in fact, to indicate any 
original aflfection of the spinal cord. The functions of the brain 
also were natural, and there was nothing about him to lead me to 
suspect cerebral disease. He had, however, considerable impair- 
ment of the muscular functions of the lower extremities, and could 



i 



PARAPLEGIA. 107 

not walk without the aid of crutches, or some person to support 
him. In treating his case, I looked upon it as an instance of 
imperfect paraplegia, in which the paralysis apparently rose from 
impressions made upon the sentient extremities of the nerves of the 
legs and feet, at a time when these nerves were particularly liable 
to be deranged in their functions from the previous use of mercury. 
I therefore had recourse to remedies directly applied to the extremi- 
ties of those, nerves, and fortunately succeeded in restoring this 
gentleman to the use of his Hmbs. The cure, however, was not 
perfect, for a very notable degree of weakness still remains. 

Of this form of paraplegia I have now witnessed many instances. 
Jn most cases I was induced to think that it arose from impressions 
made by cold and wet on the lower extremities. It is most com- 
monly observed in young gentlemen who are addicted to fishing 
and shooting, and who in pursuits of their amusements get wet feet 
repeatedly, from walking over boggy grounds, or wading in the 
water. It is also observed in labourers whose employment obliges 
them to stand in water for many hours together, as in draining, 
pump-sinking, and other similar occupations. In all cases it as- 
sumes the creeping form^ and generally appears at first in one limb, 
and afterwards in the other. There is, however, considerable va- 
riety in the rate of its progress ; in some cases the patients become 
almost completely paraplegic in a few weeks from the commence- 
ment of the disease, in others it will go on for months, and even 
years, before the power of the lower extremities is completely de- 
stroyed. Where its progress is slow, it makes its approach in an 
insidious manner, and is at first scarcely noticed by the patient. Its 
latency is here further favoured by the absence of pain, numbness, 
or formication ; for it is only at the more advanced stages of such 
cases that derangement or diminution of sensation is noticed. It is 
only when making some unusual exertion, as in going up stairs or 
ascending a hill, that the patient finds a more than ordinary degree 
of weakness in the lower extremities. The first symptom which 
generally attracts his attention is an incapability of walking as far 
as he has been accustomed, but this is attributed to some temporary 
weakness, or is considered to be the result of previous fatigue. As 
the disease progresses, walking up an ascent becomes a matter of 
some difficuky, there is a shuffling motion of the legs, and the pa- 
tient is apt to stumble from slight obstructions. Gradually the loss 
of power becomes more manifest, it excites the attention and sur- 
prise of the patient, and he finds that he is no longer able to walk 
without the aid of a stick or some person to lean on. The paralysis 
is, however, seldom complete; with the help of crutches the patient 
continues to hobble about, and it is only in bad cases, and at an 
advanced period of the disease, that he becomes completely para- 
plegic. The paralysis is never so sudden nor so complete in this 
form of paraplegia, as it is in cases of disease of the spinal cord, 
or scrofulous ulceration of the bones and ligaments. 

In other cases, however, the paraplegia, though evidently of the 



108 GRAVES'S CLINICAL LECTURES. 

same origin, and having the same creeping character, advances 
with much more rapidity ; and the patient may, in a few weeks from 
the commencement of the attack, experience .a very considerable 
diminution of power in the lower extremities. In such cases it 
will be generally found that one limb is much more affected than 
the other, the loss of power being most complete in the limb which 
was first engaged. 

With respect to sensation, it appears to be affected as well as 
motion. In the slow and chronic form of this species of paraplegia, 
it does not attract the attention of the patient so quickly as the 
derangement of muscular power ; it is generally some time before 
he notices any diminution of sensation, and then accidentally. In 
the more advanced stage, however, this becomes manifest, and is 
accompanied by a sensation of cold in the lower limbs, which sel- 
dom extends higher than the knees. In the more rapid and acute 
form, the derangement of sensation is much more obvious, and is 
generally the first symptom noticed by the patient. There is at 
first a feeling of numbness, which commences in the toes or feet, 
and extends up the limb : this, in the course of a few days, is fol- 
lowed by formication and tingling pains in the course of the nerves, 
and then loss of power and diminished sensation. There is, how- 
ever, in both of these forms of paraplegia, much less impairment of 
sensation than of motion, and the loss of sensation is never so com- 
plete as in paraplegia from disease of the spine. 

There is one curious symptom occasionally observed in this dis- 
ease, which is that, before the appearance of any decided symptoms 
of loss of power in the lower extremity, irritation of the lower part 
of the digestive tube takes place ; the rectum becomes morbidly 
excited ; the patient complains of tenesmus, and thinks he is about 
having an attack of piles. This was the first symptom observed in 
one of the cases I attended ; the patient complained so much that 
w^e were induced to examine the state of the rectum, but could not 
find anything to account for the morbid excitement. The same 
observations apply to the bladder, with this exception, that the 
morbid irritability of this organ occurs occasionally after the disease 
is confirmed and has made considerable progress. On the whole, 
however, affections of the bladder and rectum are rare in this form of 
paraplegia ; and it is only at the advanced stages that we sometimes 
meet with that derangement in the motor powers of the bladder and" 
rectum, which occurs so frequently, and at such an early period, in 
the paraplegia from spinal disease. 

In cases of paraplegia from disease of the spinal cord or its 
investments, it has been observed that the urine becomes altered in 
its quality, and assumes an ammoniacal odour. I have not observe^ 
this occurrence in the forms of paraplegia that I have detailed. The 
urine is turbid, scanty, and voided oftener than usual : but I cannot 
say that I have seen it in any case decidedly ammoniacal, even in 
the advanced stages of the disease, and where the patient was com- 
pletely bed-ridden. Should future observations prove that this 



PARAPLEGIA. 109 

diagnostic mark is constant, it naay be of some value in distinguish- 
ing this from other forms of paraplegia. 

In these cases there is scarcely anything which would lead us 
to fix on the spine as the seat and origin of the disease; neither can 
we find anything in the brain with which we can connect the 
paraplegic symptoms. There is no pain of the head or spine, very 
seldom any tenderness, the patients are in the full vigour of intel- 
lect, and all the organs of sense in their normal condition. The 
functions of respiration and circulation are unaffected : and it was 
remarked in the first case which I have detailed, that there was no 
change in the pulse, either during the fits of vomiting, or the inter- 
vals of ease. The appetite also is generally good; but, in almost 
every instance I have met with, there has been remarkably obsti- 
nate constipation. 

With respect to the prognosis and treatment of this form of para- 
plegia, I have but little to say. The prognosis is generally unfa- 
vourable, particularly where the disease has lasted for some tim.e, 
and is accompanied by morbid irritation, or loss of power in the 
bladder or rectum. It is also bad in proportion to the slow^ness 
with which it has come on, and the absence of pain or formication 
of the lower extremities. With respect to treatment, I may observe 
that I have never seen any benefit derived from applications to the 
spine. The application of blisters or issues over the back or loins, 
does not appear to be productive of the least good effect; of the 
latter, I can speak positively from experience. They are an en- 
during source of annoyance to the patient, and never produce the 
least amelioration of symptoms. I am in the habit of applying my 
local remedies to the legs and thighs, selecting those parts in which 
the greatest cutaneous sensibility exists. What I generally do, is 
to keep up a succession of blisters along the inside of the legs, and 
over the anterior and inner parts of the thighs. The practice oi 
medicine furnishes many proofs of the utility of stimulant applica- 
tions to the nervous branches, in case of disease affecting the larger 
trunks. Thus, in sciatica, a blister applied over the ham or calf of 
the leg, where many of the ultimate ramifications of that nerve are 
superficial, will frequently produce a much more decided effect than 
when applied over the origin of the nerve itself. Liniments of a 
stimulating kind, and blisters repeatedly applied, are the local 
means on which I chiefly rely in the treatment of this form of para- 
plegia. After some time, I commence with the use of strychnine, 
and continue it until some sensible effect on the system is produced, 
when I omit its further use, and have recourse to the exhibition of 
sulphur. These are the two internal remedies from which I have 
derived most benefit. I have in such cases seen very good effects 
from a perseverance in the use of the sulphur electuary, of which I 
have given a formula in one of my published lectures. Much also 
will be accomplished by the external use of sulphur, in the form of 
baths, and hence cases of paraplegia of this kind might be mate- 
rially benefited by the internal and external use of the waters of 

10 



no GRAVES'S CLINICAL LECTURES. 

Lucan, Harrogate, Baden, Barege, &c. With respect to the use of 
mercury, it appears to be decidedly injurious. I have seen it given 
in three cases; in all it did much more harm than good.* 

This is all I have to say at present on the subject of paraplegia. 
I fear much that many omissions, and considerable deficiency of 
materials, will be observed in the statements I have laid before you. 
I hope, on some future occasion, to be able to communicate a more 
minute and better digested series of observations on this obscure 
form of disease. The subject, however, is in itself so interesting, 
and so important, that I have been tempted to bring it before you, 
perhaps prematurely. My anxiety to excite discussion, and attract 
further attention to a department of practical medicine hitherto 
quite neglected, must on this occasion plead my excuse. 



LECTURE IX. 

Case of peritonitis and enteritis terminating in fatal convulsions — Enormous accumu- 
lation of lumbrici in the bowels, producing death by convulsions — Causes of catarrhal 
affections of the bronchial tubes — On the rales produced by bronchitis — Remarkable 
proportion between the frequency of the pulse and the respiration — Use of emetics 
and chaiybeates in chronic bronchitis — Symptoms which contra-indicate chalybeate? 
— Trismus from inflammation of the temporal muscles — Pain in the nerves of the 
face, simulating tic douloureux, and caused by a carious tooth — Case of jaundice, 
with remarks — Connection between arthritis, jaundice, and urticaria — Analogous 
series of affections often caused by eating fish. 

Let me direct your attention for a few moments to a case which 
presents some interest, as connected with the obscurity of its nature ; 
I allude to that of the young woman, Moran, who died this morn- 
ing. She came in, on Monday week last, with symptoms of ordi- 
nary continued fever, for which the only remedies employed were 
effervescing draughts, diluents, and a proper attention with regard 
to diet. She had some headache, which went away a few days 
after her admission ; and, as she made no other complaint, her case 
was looked upon as one of simple fever. Some time afterwards, it 
was observed that her abdomen was tympanitic, and that she had 
diarrhoea; but she persisted in denying that she had any abdominal 
pain or tenderness. In addition to this, symptoms of bronchial in- 
flammation set in, but without any remarkable distress of respira- 
tion, or acceleration of pulse. She made no complaint whatever, 
and seemed extremely unwilling to communicate any information 
respecting her condition. Under these circumstances, all that could 
be done was to treat the symptoms as they became manifest, and, 
accordingly, after having leeched the belly, I ordered a large blister 
to be applied so as to cover the epigastrium and lower part of the 

* [The hot springs of Virginia are often of great benefit in these cases, espe- 
cially the hot douche, or spout-balh, — Ed.] 



PERITONITIS AND ENTERITIS. ] 1 1 

chest anteriorly. The only thing remarkable in her case, and to 
which I should have called your attention more particularly, was 
the repeated occurrence of rigors. It appeared, from the account 
given by the nurse, that she had frequent attacks of shivering on 
last Friday, and the two preceding days; and I have already told 
you, that where this occurs, you should always suspect the exist- 
ence of some local inflammation. 

Such were the principal phenomena observed in this case. On 
Saturday, she stated that she felt better after the application of 
leeches, and had no pain or tenderness whatever in the belly; but 
still it was observed that the tympanitis was undiminished, and that 
she was not by any means improving. This morning she called to 
the nurse to assist her in getting to the night-chair, when, after a 
few minutes, she was suddenly seized with a violent convulsive fit, 
and expired. 

I may observe, that there was nothing in this case which would 
lead one to suspect the existence of cerebral inflammation. The 
fever was of the ordinary kind; there was no remarkable accelera- 
tion of pulse (the number of beats in the minute being only 84 when 
we examined her on Saturday) ; she had some headache, but this 
did not continue ; and there was no flushing of the face, redness or 
suftusion of the eyes, heat of scalp, or throbbing of the temporal 
arteries. There was nothing to inform us that disease was going 
on in the brain, and yet the patient dies violently convulsed. Un- 
der these circumstances, how are we to explain the manner of her 
death ? At present, I believe it would be better not to enter on any 
inquiry respecting this point. I shall endeavour to procure a n 
examination of the body, and, until then, shall make no further 
observation. 

On opening the body the next day, no trace of disease could be 
found in the brain. The thoracic viscera were also healthy, with 
the exception of some vascularity and congestion of the bronchial 
mucous membrane. In the abdomen there were ample marks of 
extensive inflammation. The cavity of the peritoneum contained 
a quantity of serous fluid; the intestines were glued together by 
lymph at almost every point of contact; and the serous membrane 
was highly vascular. The mucous membrane of the intestines 
was extensively inflamed^ and there were numerous small ulcers in 
the situation of the glands of Peyer. The uterus, with its append- 
ages, was in a state of intense inflammation, and presented marks 
of recent delivery. It appeared afterwards, that she had been 
delivered of a male infant, the fruit of an illicit intercourse, a few 
days before her admission into the hospital. Under the influence 
of shame, and a desire to conceal her condition, she had, through- 
out her illness, persisted in strongly denying the existence of any 
abdominal symptoms whatever. 

Here this question, — whether the disease might have been cured 
had its true nature been discovered on her admission, — naturally 
suggests itself. I must candidly confess that I think it might ; and 



112 GRAVES'S CLINICAL LECTURES. 

I regret extremely that the peculiar circumstances of the case ren- 
dered her anxious to conceal the existence of the symptoms of ab- 
dominal inflammation ; for had it been otherwise, a more active 
antiphlogistic and mercurial treatment might, perhaps, have been 
successfully applied. 

This case affords another example of the truth of what I endea- 
voured to establish in a former lecture, concerning the effects which 
irritations of the periphery are capable of producing on the central 
portions of the nervous system ; for here death was induced by con- 
vulsions, the mediate cause of which was situated not in the brain 
but in the abdomen. A very remarkable and striking case of a 
somewhat similar nature, has been lately published by Dr. Eber- 
maier, in RusVs Magazine (Vol. 42, Part I., p. 52, et seq.), in 
w-hich the abdominal irritation, caused by an enormous collection 
of lumbrici in the small intestines, occasioned, in a child who had 
previously enjoyed good health, a sudden attack of pain in the 
belly and vomiting, terminating speedily in fatal convulsions. The 
intestines were not inflamed, but were completely obstructed, in 
many parts of the ileum, by successive round masses, formed by 
agglomerations of lumbrici, rolled up together, and enveloped in an 
adhesive paste fornied of half-digested bread, cemented by a tena- 
cious mucus. The worms were too numerous to count, amounting 
to many hundreds. 

A man named Murray, of middle age and rather strong constitu- 
tion, has been recently admitted into the small chronic ward, with 
bronchitis of lo.ng standing, and frequent exacerbations. It is a 
case in which I am afraid a permanent cure is out of the question, 
and so far it is unsatisfactory ; still it is necessary to be acquainted 
with such cases, for it is a matter of some importance to be able 
to inform a patient whether his disease is curable or not, and how 
far it admits of being relieved by treatment. 

Bronchitis is an affection which generally arises from impressions 
made by cold, either on the skin or on the mucous membrane of the 
lung. I think it extremely probable that, when a person gets a 
catarrhal affection from exposure to cold, it is not always in conse- 
quence of an impression made on some part of the cutaneous sur- 
face. Indeed, it appears reasonable to 'believe that an attack of 
bronchial inflammation may be equally the result of an impression 
made directly on the mucous lining of the lung ; and that a person 
exposed to sudden change of temperature, as in passing from a 
heated room into the cold air, may get inflammation of the mucous 
membrane of the bronchial tubes, for the same reasons that, under 
similar circumstances, inflammation may be generated in the mucous 
membrane of the eye, giving rise to conjunctivitis. We know 
well that one of the most common causes of inflammation of the 
conjunctiva, is the sudden exposure of the eye to cold sharp air, 
after it has been for some time submitted to the relaxing influences 
df strong heat and light ; and there is no reason why the same rapid 
change of temperature, under similar predisposing causes, should 



BRONCHITIS. 113 

not originate disease in the mucous mennbrane of the bronchial 
tubes. It is true, indeed, that nature has taken especial pains to 
maintain an equable? temperature in the air admitted into the chest 
at each respiration ; the passage of this air through the mouth, nose, 
and pharynx, where it is warmed by the contact of an extensive 
mucous surface, and the small proportion "which it bears to the 
residual air remaining in the lungs after an ordinary expiration, 
are circumstances that must powerfully counteract the low tempe- 
rature of air inspired in very cold weather. Still a considerable 
difference of temperature must exist between the inspired and ex- 
pired air, and consequently the air passages are exposed, more than 
any other tissue of the body, to successive and rapid alternations, 
which never cease from infancy to old age. Nature has, of course, 
wisely accommodated the vitality of the bronchial mucous mem- 
brane to the circumstances in which it is placed, and the force of a 
never-ceasing habit still further enables it to sustain rapid vicissi- 
tudes of temperature with impunity. In this it is probably equalled 
by the surface of the eyeball, which, alternately covered, warmed, 
and moistened by the eyelids during the act of winking, and ex- 
posed to the cold of the air, increased by a rapid evaporation from 
its own surface while the eye is open, must, indeed, undergo rapid 
variations of temperature, and yet it is never frost-bitten. 

When inflammation has fastened on the mucous membrane of 
the air passages, it makes a vast difference as to the part on which 
it fixes. The air passages commence with the larynx, and termi- 
nate with the ultimate ramifications of the bronchial tubes. If the 
disease settles at the entrance of the air passages, and forms laryn- 
gitis, the case becomes a very serious one, laryngitis being in the 
infant, and sometimes also in the adult, attended with dangerous 
and even fatal symptoms. If the trachea should happen to be the 
part on which the disease falls, the inconvenience and suffering are 
also considerable, but the danger is by no means so urgent as in the 
former case. The same thing may be said of the larger bronchial 
tubes; inflammation here is rarely attended with such violent 
symptoms as those which characterize laryngitis, and it is much 
more amenable to treatment. But when inflammation attacks the 
minute bronchial tubes to any considerable extent, and particularly 
if it happens to be general — that is, if it affects the bronchial tubes 
in every part of the lungs — we have just grounds for alarm ; the 
disease is one of an intense character, and, unless quickly relieved, 
runs on to a fatal termination with great rapidity. 

You perceive, then, that if a patient catches cold, and gets an 
attack on the chest, it is of great importance to be able to ascertain 
what the situation and extent of the disease are, and whether the 
minute bronchial tubes are engaged or not. Now^ how do you 
know this] Simply thus: — You first make a cursory examination 
of the whole chest, by applying the stethoscope over the superior, 
middle, and inferior portion of each lung, both before and behind ; 
and, if you everywhere hear*something, you conclude that the 

10* 



1 1 4 GRAVES'S CLINICAL LECTUKESL 

bronchitis is general, and not confined to anypartieolar part. Yon 
next proceed to examine with greater attention these wheemng 
sounds ; you apply the stethoscope, and if yop find in each sepa- 
rate spot many sources of diseased sonnd — ififouhearawkeedng 
from a great many points close together — yon may be sure that 
the morbid soaud proceeds from inflammation of the minute tubes, 
for the larger ones cannot exist in the small spots over which you 
apply the stethoscope in such nambers as to give rise to so remarka- 
ble a plurality of sounds. Of this yoo may be certain, that, when 
you find a great many sounds are audible over a small space, the 
minute broochial ramifications are engaged. 

It is the custom, with those who lecture on auscultation, to enu- 
merate many sounds as connected with alterations ia the condition 
of the bronchial tubes. We hear of the mucous, the sonorous, and 
the sibilant rhonchus — their variety and intermixtures, ^ow I 
know, by experience, that these names are very apt to confuse and 
perplex the young stethoscopist. There is no necessity for studying 
with great attention the definitions of these words, or the descrip- 
tions of the various sounds they are meant to represent: lam 
always anxious to avoid loading the memory of the student with 
names. With regard to the rales in bronchitis, all he need bear in 
mind is, that the nature of the sound produced by air pa^ng 
through the bronchial tubes will be modified accordingly as these 
tubes are large or small, are dry or moist, or as the moisture they 
contain is thin or not. The two things of greatest importance in 
examining a case of bronchitis is to ascertain whether the minute 
bronchial ramifications are engaged, and,^if the tubes contain arv 
moisture, whether it is thin or viscid. 

I seldom, therefore, confuse the student by telling him whether 
the rale is sibilant or sonorous, when asked aboul the nature of the 
sounds heard in a case of bronchial inflammation. All I say in 
reply is this : that the sounds are produced by the large or small 
bronchial tubes, and that they are either moist or dry. When the 
large bronchi alone are inflamed, the sounds issuing firom the long 
subjacent to the stethoscope are comparatively few in number, sel- 
dom exceeding two or three ; they are likewise, when dry, of a 
grave tone, r^embhng the prolonged note of a violoncello, or the 
cooing of a dove ; or, when moist, the bubbles are large, scattered, 
uneven. When the minute tubes are engaged, we hear, on the 
contrary, not a few, but many sounds, evideatly proceeding from a 
small portion of lung ; three, four, or even six or seven sounds may 
be perceived together, or circumscribed within very narrow limits. 
These sounds undergo rapid changes of tone during the same 
r^piration, while every moment some of them appear to cease, to 
be replaced by new ones. The wheezing they produce is, when 
dry, sharp ; but observe, it is very unusual to find every one of 
them dry : when dry sounds occur, they are generally accompan'c i 
by others, equally minute, but evidently moist The momeni i 
find, on applying the stethoscope, that a great many sounds are 



SOUNDS HEARD IN THE CHEST. 115 

heard over a small spot, and that these sounds are dry and sharp, 
or are accompanied by certain modifications denoting the passage 
of air through fluid, I call the disease inflammation of the minute 
bronchial tubes, with increased secretion obstructing the free en- 
trance of air. An attention to these considerations is of great 
importance in ascertaining the nature of acute or chronic bron- 
chitis ; for the danger is not only proportioned to the extent of the 
disease, but also the circumstance of the minute tubes being engaged, 
and the quantity of fluid they contain. The sound shows that not 
only the minute tubes are diseased, but also that there is a consider- 
able quantity of viscid fluid in them, preventing the entrance af air 
into the air ceils, and tending to produce asphyxia. 

In the case we are at present considering, we found, on examin- 
ing the chest, that the minute bronchial tubes were extensively 
engaged, and they were obstructed by a copious secretion of mucus 
producing considerable dyspnosa. We found, however, that this 
condition had lasted for many months, and that the disease was 
essentially chronic. He had no fever ; his skin was cool ; his tongue 
moist; appetite and digestion good; and his pulse, which had beeo 
only 60 on his admission, sank to 46 after he had been in bed for 
some days. Such extreme slowness of pulse as this is a very re- 
markable circumstance, particularly in cases of pulmonary disease; 
it is seldom met with except in cases of cerebral affections. Here 
was a man breathing twenty-six times in a minute, and with a 
pulse at 46 ; whereas, if the pulse was proportioned to the respira- 
tion, it would have been much quicker. The relation of the num- 
ber of respirations to the beats of the artery at the wrist should be 
as one to four; thus, when we bre-athe fifteen times in a minute, 
the pulse should be at 60. But here we find a man breathing 
twenty-six times in a minute, and yet his pulse is only 46. We 
had another instance like this, in a patient in the chronic ward, 
whose pulse was 60, while his respirations were thirty-six in a 
minute. It seldom happens, when pulmonary disease is in the 
acute form, and respiration considerably accelerated, that there is 
not a corresponding increase in the frequency of the pulse ; but, in 
chronic cases of this description, the system becomes gradually 
accustomed to the derangement; the continued acceleration of 
breathing ceases to affect the action of the heart ; the lung, which 
is obstructed by disease in the performance of its functions, con- 
trives, by working more frequently, to aerate the requisite quantity 
of blood, and, the heart adapting itself to the change of circum- 
stances, the pulse returns gradually to the natural standard. I 
have seen many cases of phthisis, in w^hich there was accelerated 
breathing, with slow pulse, but these were always cases of a chronic 
kind. I have never observed the same phenomena co-existing when 
the disease was acute ; it is a state of things which is compatible 
only with chronicity of disease, in which the system becomes 
gradually accustomed to the change, and a kind of artificial equi- 
librium is finally established. 



IIG GRAVES'S CLINICAL LECTURES. 

In this case we find that a man of tolerably good constitution, 
after exposure to cold, gets an attack of bronchitis, which becomes 
chronic and extends almost over the whole lung. He has a cough 
always existing — sometimes better, sometimes worse, occasionally 
aggravated. This cough is accompanied by a copious secretion of 
raucus; and this state of things continues for more than twelve 
months. jNow, when bronchitis has lasted so long on persons of 
his class in life, it is very difficult to be cured ; his poverty, his 
want of proper clothing, his liability to the ordinary exciting causes 
of bronchitis from the nature of his employment, and the habitual 
disregard of self so constantly observed in persons of this descrip- 
tion, are all circumstances which forbid us to entertain any hopes 
of giving permanent relief. 

There are two points to be attended to in the treatment of this 
and every other case of chronic bronchitis : first, whether there be 
any recent attack, and consequently any fever and exacerbation of 
the local symptoms present; and, in the next place, whether the 
secretion from the bronchial mucous membrane be CDpious or 
scanty. Now, at the period of this man's admission, there was 
some slight excitement of the pulse, but there was no fever or in- 
crease of bronchial inflammation present, and the heart's action 
was apparently not influenced by the state of the lung. In addition 
to this, there was no urgent dyspncsa, and the secretion from the 
lungs was extremely abundant. We therefore commenced by ad- 
ministering an emetic, which was repeated for two or three days, 
and then prescribed the following mixture : Mist, ferri composita, 
5ij: tinct. scilfe, tinct. hyoscyami, aa 9J ; to be taken three times 
a day in an ounce of almond emulsion. In chronic bronchitis, 
where no fever, no remarkable dyspnoea or acceleration of the 
pulse is present, and where the bronchial secretion is very copious, 
you will be able to produce very good effects by giving an emetic 
every night for two or three nights, before you begin with remedies 
calculated to arrest the supersecretion from the lung. They are 
productive of a double advantage in such cases: a large quantity 
of mucus is discharged from the stomach and lungs, expectoration 
is rendered more easy, the tongue cleans, and the appetite is im- 
proved. It was on this account we gave them in the present case, 
and, as you may have perceived, with much benefit. In no disease 
are we more apt to have a foul, loaded, and furred tongue, than in 
bronchitis. This state of the tongue, being usually accompanied 
by loss of appetite and indigestion, is frequently attributed to arbad 
stomach. Now the truth is, that in such cases the state of the 
tongue and the state of the stomach are both produced by one and 
the same cause — viz., the unnatural state of the bronchial mucous 
membrane. In the latter tissue the train of morbid actions com- 
menced, and from it was derived that source of irritation which, 
inducing disease in the bronchial mucous membrane, caused a state 
of parts rapidly propagated along that membrane to the mouth and 
tongue on the one hand, and to the stomach on the other. We 



EMETICS AND CHALYBEATES IN BRONCHITIS. 117 

afterwards had recourse to a tonic and astringent chalybeate — the 
mist, ferri comp. — with the view of improving the general system, 
and checking the superabundant secretion from the bronchial tubes. 
The action of a chalybeate is not merely limited to strengthening 
the tone of the stomach and general system ; it is also well calcu- 
lated to arrest the superabundant secretion from mucous surfaces 
in many chronic fluxes, and hence its utility in gleet, diarrhoea, and 
chronic bronchitis. We gave the compound iron mixture in prefer- 
ence to a simple chalybeate, because the other ingredients — namely, 
myrrh and sub-carbonate of potash — have a tendency to produce 
the same effect. I do not, however, prescribe this medicine in such 
large doses as I have frequently seen ordered, and I never give it 
alone. I order a dram or two to be taken three times a day, and 
I dilute this quantity by adding to it half an ounce or an ounce of 
almond emulsion or mint water. In this form it is a much safer 
remedy in the treatment of fluxes depending on chronic inflamma- 
tion, and its exhibition is much less likely to be followed by sinister 
accidents. I have, in the present instance, combined with it a small 
quantity of squill; the reason of making this addition is so obvious 
that it is unnecessary for me to do more than to notice this fact. I 
have also added some tincture of hyoscyamus, which is an ex- 
tremely valuable sedative in the treatment of many forms of pulmo- 
nary disease. 

However well planned this treatment seemed to be, it did not 
succeed. After taking the mixture for a day or two, the man began 
to complain of tightness across his chest, and we were obliged to 
give it up. I have already stated, that in cases of this description, 
where the patient is using remedies to arrest secretion, you should 
be cautious in administering them at first, and attend carefully to 
their effects. If, after a patient has been using a chalybeate, or any 
remedy administered for similar purposes, you find that constric- 
tion of the chest and dyspnoea is increased, no matter whether the 
secretion is diminished or not, you may be sure that you are doing 
more harm than good. When the remedy acts favourably, you 
may know it by the following signs : — respiration becomes less fre- 
quent, and is performed with less distress, the expectoration be- 
comes more free, the sputa begin to assume the globular form, its 
quantity is diminished, and it is less tenacious and viscid in its con- 
sistence. When you give a stimulant, therefore, in chronic bron- 
chitis, you must watch its effects with care, and if it produces any 
increase in the difficulty of respiration, or any pain or tightness of 
chest, you must omit it altogether, and pass to an expectorant of a 
less irritating character. In this case we stopped the use of the 
mistura ferri composita, and immediately ordered the patient to take 
a grain of tartar emetic in a pint of whey. This simple remedy 
succeeded in a very remarkable manner, producing on the first day 
a very considerable alleviation of symptoms. 

A man was admitted into the chronic ward a few days ago who 
cannot separate the lower from the upper jaw to the distance of 



1J8 GRAVES'S CLINICAL LECTURES. 

more than two lines. What are the cases in which we find this 
immobility of the lower jaw ? Most common!}^ in tetanus or locked- 
jaw ; but here this cannot be the case, for the man has no sign in- 
dicative of a tetanic affection, no rigidity of the muscles of the neck ; 
his countenance is very different from that of a tetanic patient, and 
he has not been exposed to any of the ordinary exciting causes of 
that disease. But leaving all consideration of the nature of the 
disease out of the question, what is it that prevents him from moving 
his lower jaw ? It must depend on one of two causes ; either the 
muscles which perform the motions of the lower jaw are stiff, rigid, 
and incapable of motion, or else there is some disease of the articu- 
lation which obstructs the motion of the bone. This proposition is 
universally true of all articulations, that when they become impeded 
or completely obstructed in their motions, the derangement arises 
from some abnormal condition of the muscles, or of the bones and 
ligaments which form the joint. 

In this case we find, that, in addition to being unable to perform 
the proper motions of the lower jaw, the patient has intense pain, 
darting from the angle of the jaw towards the temple, the ear, and 
the side of the neck. This pain is of an extremely violent cha- 
racter, so as to resemble tic douloureux, and the resemblance is still 
farther increased by its being more or less intermittent. Now% on 
inquiry into the histor}^ of this case, we find that the patient had 
some time ago laboured under toothache, for which he got the last 
molar tooth but one of the upper jaw extracted, and that immedi- 
ately afterwards he was seized wMth violent pain in the part, and 
found that he could no longer move his lower jaw as usual. I 
have seen many cases of this kind, in w^hich a painful or carious 
tooth, or an injury done to the gum or jaw, has been followed by 
violent darting pain in the nerves of the face, simulating in many 
particulars tic douloureux. I remember being sent for to Middle- 
ton, near Cork, some time since, to see a young lady of delicate 
constitution, whose health was materially deranged from what was 
said to be an attack of tic douloureux. She had been under the 
care of many practitioners, and had used very large doses of the 
carbonate of iron and sulphate of quinine, and at the time I visited 
her w^as taking arsenic. The first thing I did on my arrival was 
to examine her teeth. On close inspection I observed that on the 
crown of one of the upper molar teeth there was a spot which ap- 
peared to be decayed, and found on inquiry that she had frequently 
suffered from pain in this spot when she drank any cold liquid. I 
had the tooth drawn, and soon afterwards the pain completely ceased. 
Yet in this case the pain was not only of an intense character, pre- 
venting sleep and wearing out her strength, but it had its intermis- 
sions, and was aggravated at particular hours of the day. Another 
instance of the same kind came under my notice about twelve 
months ago. A young lady was brought to me by a medical friend 
of her's to have my advice for an attack of tic douloureux. She 
had been attended by this gentleman with great care, and no mode 



CASES SIMULATING TIC DOULOUREUX. 119 

of relief left untried, for her sufferings were intense, and she had 
constant exacerbations of pain. I asked him, were her teeth sound, 
or had she any disease of the gum or jaw ? He said not, and that 
he was sure of this, for he had examined her teeth over and over 
again. On opening her mouth, however, I thought I saw some 
appearance of unsoundness in one of her teeth, and recommended 
her to go to Mr. M'CIean and get it drawn. She did so, and the 
pain quickly disappeared. I could also give many cases in which 
an injury done to some of the branches of the dental nerve has 
given rise to symptoms closely resembling those of the tic doulou- 
reux. One of the most curious circumstances connected with such 
cases is, that the pain is always of a more or less intermittent cha- 
racter. The same thing is observed in that form of headache which 
arises from irritation of the brain, produced by spicul^e of bone 
growing from the internal table of the skull. In a case which 
occurred some time back at the Meath Hospital, where several spi- 
cules, some of them more than a quarter of an inch in length, were 
pressing on the brain, the headache was of a distinctly intermittent 
character. This remarkable periodicity of exacerbation, in cases 
where the operation of the exciting cause continues still the same, 
seems to be peculiar to the nervous system. 

In many cases considerable derangement of the facial nerves is 
found to follow an injury done to some branch of the dental nerve 
in drawing a tooth. When the bone has been injured by the force 
used in extracting the tooth, it frequently happens that, if the injury 
be not quickly repaired, and the parts healed up, symptoms resem- 
bling those of tic douloureux or rheumatic neuralgia will supervene, 
and give the patient a great deal of annoyance. Such was the ori- 
gin of the mischief in the case before us ; the man received an injury 
of the upper jaw in drawing a tooth, which is not as yet healed, as 
you may perceive by introducing a probe between the separated 
portions of gum, when you will find it grate against the rough sur- 
fece of the bone. In addition to this, there is considerable tenderness 
of the gum and swelling of the neighbouring parts, w^hich have 
extended to the muscles, their sheaths, and finally to the articulation 
of the lower jaw. You can satisfy yourselves of this by examining 
the parts and striking the lower jaw, so as to pres^it suddenly up- 
wards and backwards into the glenoid cavity, just in the same way 
as you press the thigh bone against the acetabulum when you wish 
to ascertain whether there is inflammation of the hip joint. The 
motion of the lower jaw is here prevented by inflammation, ex- 
tending from the upper jaw so as to involve its ligaments and the 
neighbouring muscular sheaths. There are other causes, also, 
■which may be attended with the same diminution of motion in the 
joint. Thus a man may get an attack of rheumatism in the scalp, 
■which may extend to the temporal muscles and prevent him from 
being able to depress his lower jaw, and I have known cases in 
which this condition of the temporal muscle has given rise to sus- 
picions of the existence of trismus. When you examine the articu- 



120 ' GKAYES'S CLLXICAL LECTURES. 

lation you find nothing amiss, but when yon come to press on the 
temporal muscle above the zygoma, the patient complains of pain 
and tenderness. The irritation produced by rheumatic inflamma- 
tion gives rise to a fixed rigid state of the muscle, and hence the 
patient cannot open his mouth. This form of disease I have de- 
scribed long since, in a paper published in the Dublin Hospital 
Reports. It can be relieved with great ease by applying leeches to 
the temple, and ordering the patient to rub over the part a small 
portion of mercurial ointment with extract of belladonna, two or 
three times a day. The same state of the temporal muscle is sonie- 
times observed as resulting from an extension of inflammation, in 
case of a wound of the scalp in its vicinity. 

In the case before us, almost everything will depend on the 
process which nature may adopt with respect to the injury of the 
maxillary bone. If the bone throws up healthy granulations, and 
the inflammatory process ceases, the affection of the nerves, as well 
as of the muscles and joint, will quickly subside. All we can do 
under the circumstances is to apply leeches over the side of the face, 
and order the man to rub in mercurial ointment; everything, how- 
ever, will depend on the turn the disease of the bone may take. 

I wish to make a few observations on a case of jaundice in the 
small chronic ward. I do not intend to enter into any particular 
inquiry concerning the causes of this disease ; you are aware that 
it may depend upon many causes, upon afiections of the mind, 
gastro-duodenitis, inflammation or abscess of the liver, the presence 
of gall-stones, diseases of the head of the pancreas, aneurism of the 
hepatic artery, and, what is more remarkable, in some cases may 
arise without any assignable cause whatever. In the present in- 
stance it seems to have been the result of acute hepatitis. The 
man was attacked with symptonis of inflammation of the liver, and 
about a fortnight afterwards became jaundiced. It is unnecessary 
for me to draw your attention to the history of the case, or the pre- 
sent state of the patient; all I shall do at present is to make a few 
remarks on some point of treatment. 

In the first place, the jaundice is, as you perceive, of an intense 
character; the man is as yellow as he could be. Now this I look 
upon as a favourable sign ; the deeper the colour is in recent cases 
the greater is the chance of eflecting a cure. There are no cases so 
untractable as those in which the tinge of yellowness is so faint 
that you would be likely to overlook it, as in the case of a man in 
the chronic ward, in whom the colouring is so slight, that it re- 
quires some attention to ascertain whether he is jaundiced or not. 
Such a case as this is always of a chronic, untractable character, 
and this is too frequently connected with a scirrhous state of the 
liver. Again, in this man's case we cannot detect any appearance 
of bile in the evacuations : this is another good sign. Vv'hen jaun- 
dice co-exists with bilious stools, the prognosis is, generally speak- 
ing, bad. A but slight tinge of yellowness of skin, and the con- 
tinued presence of bile in the stools, are two circumstances which I 



JAUNDICE WITH ARTHRITIS AND URTICARIA. 121 

always look upon as indicative of an unmanageable and frequently 
incurable afTection. It generally depends on a scirrhous state of 
the Uver, or some organic derangement beyond the power of medi- 
cal treatment. Again, another good sign in jaundice is, that as long 
as the bile is absent in the stools it should be present in the urine. 
If a patient labouring under jaundice has clay-coloured stools, 
and you find on examination that his urine becomes heavily laden 
with ii, it is a very favourable circumstance, for it shows that, al- 
though the usual channel for the exit of bile from the system is 
stopped up, nature has provided a remedy for the evil by establish- 
ing another emunctory. You can understand then the reason of 
the anxiety I felt at finding that this patient's urine was becoming 
paler and diminishing in quantity, at a time when bile was not 
present in the stools. In acute cases of jaundice, you should always 
bear in mind that patients will sometimes have a complete sup- 
pression of the biliary discharge, followed by coma, without any 
symptoms of disease of the brain. Why this occurs in some and 
not in all cases we cannot understand, but from whatever cause it 
may arise, we find that in some instances jaundiced patients become 
stupid and lethargic, and die in a state of confirmed coma. In 
such cases there is always very great danger, and where coma has 
appeared as a prominent symptom of jaundice, you should always 
give an unfavourable prognosis. I have never seen but one patient 
recover under such circumstances. On the other bandit is equally 
curious that derangement of the urinary system is one of the most 
common symptoms of disease of the brain. You will therefore un- 
derstand the cause of my alarm, when I observed a diminution of the 
urinary secretion in this patient. As soon as I perceived this symp- 
tom, though the patient had been taken mercury, and was improv- 
ing at the time, I immediately administered a diuretic, and this 
fortunately succeeded in producing a copious flow of urine. We 
prescribed the following diuretic, which had not been taken for 
many hours when it produced a decided determination to the kid- 
neys : — 

Be Mistura amygdalariim, ^viij. 
Nitrat. potassse, ^ij. 
Tinct. digitalis, gtt. xv. 
Spiritus setheris nitrosi, ^U* 

of which a tablespoonful was to be taken every second hour. 

There is one practical remark to be made on this and other simi- 
lar cases. As soon as the symptoms of jaundice begin to decline, 
and bile makes its appearance in the stools, you should attend care- 
fully to the state of the patient, and note any symptom which may 
occur of an anomalous character. Now, in this patient's case, we 
observed that a degree of restlessness was present, which terminated 
in a complete want of sleep. About the time when he began to 
manifest a degree of improvement, he became quite sleepless with- 
out any evident cause, and continued so for two or three nights ; 

II 



122 GRAVES'S CLINICAL LECTURES. 

and I have already stated in a former lecture that, no matter when 
this symptom occurs, whether in fever or towards the termination 
of some acute disease, it always requires your attention. I there- 
fore immediately took proper steps to restore sleep; and accordingly 
we find, on inquiring this morning, that he has rested well and 
feels much better. The man had been taking mercury, and his 
bowels were free; but, not content with this, I gave him a purgative, 
consisting of infusion of senna with electuary of scammony. This 
he was directed to take early in the morning, so as to secure its 
operation before night ; and about nine or ten in the evening, after 
his bowels had been freely opened, he took a full opiate, which pro- 
duced a long and refreshing sleep. 

Before I conclude, allow me to communicate a few detached 
observations on the connection which exists between jaundice and 
some other diseases — as, for example, inflammation of the joints. 
It is not many years since Dr. Cheyne and 1 attended a gentleman 
in Lower Mount street, who, in consequence of exposure to cold, 
was attacked with inflammation of the joints, accompanied by con- 
siderable general fever; almost every joint was attacked in succes- 
sion, and his sufferings were excessive. The disease bore the 
form I have so often described under the name of acute sweating 
arthritis — a form very obstinate and difficult to treat, and accom- 
panied after some time with great constitutional debility. When 
this gentleman had been about ten days confined to bed under 
treatment, he suddenly became jaundiced, and it was now evident 
that acute, but not violent, hepatitis was superadded to the original 
disease. 

In a day or two afterwards, a copious eruption of nettle-rash — 
urticaria — appeared over his body and extremities. Exactly the 
same diseases appeared, and in a similar order of succession, in a 
man treated in the Mealh Hospital, in June, 1832 — an occurrence 
which at the time excited some interest among the students ; for 
when I observed that jaundice had supervened on arthritis, I men- 
tioned to the class that it was not at all unlikely that the jaundice 
would be soon attended by urticaria. I was induced at the time 
to make this remarkable prediction, as my mind was full of the 
subject, having been engaged, along with Mr. Porter, in attending 
a medical friend residing in Bagot street, in whom jaundice was 
soon followed by urticaria. Since my attention has been drawn to 
the connection between these three diseases, I have seen and heard 
of several other instances in which they appeared thus associated 
together. A circumstance so remarkable deserves to be studied 
with more than ordinary interest. Let us, therefore, consider what 
facts are supplied by physiology and pathology capable of throwing 
some light upon this hitherto unobserved and uncultivated subject. 
In the first place, nothing has been longer recognized by physicians, 
as an established fact, than the intimate sympathy which exists, 
both in health and disease, between the digestive organs and the 
skin. Now, acute hepatitis always produces more or less derange- 



URTICARIA. 123 

mem of the stomach and alimentary canal, and we may therefore 
consider its connection with urticaria in the same way that we are 
in the habit of viewing the cases, so frequently ohserved, in which 
certain sorts of fish have produced serious symptoms of indigestion 
followed by nettle-rash. The association between these two dis- 
eases is rendered more remarkable by the fact, that, when fish taken 
as food exerts a poisonous eflfect on the system, it frequently pro- 
duces not merely violent stomach and bowel complaint, but also 
inflammation of the joints and rheumatic pains. If I can establish 
this, you will allow that the connection between arthritis, disease 
of the digestive organs, and urticaria, can no longer be considered 
as fortuitous and depending on the accidental concurrence of causes 
having no determinate relation, but must be looked on as owing to 
and arising from the operation of some fixed law which regulates 
and originates this development of morbid actions in, if not a fre- 
quent, at least an uniform mode of succession. 

The Otaheitan eel (puhhe pirre rowte) produces, when eaten, a 
most copious scarlet eruption of the skin — most probably urticaria 
— and occasions sudden Himefaction of the abdomen, together with 
swelling of the extremities, hands and feet ; the pain felt in the 
limbs is so excruciating that the patient becomes quite frantic. I 
may remark here, that this, and many other species of fish which 
act as poisons on the system, give rise very speedily to paralysis of 
the extremities. You will find, in the Edinburgh Medical and 
Surgical Journal, vol. iv., p. 396, in an excellent review of Dr. 
Chisholm's work on the poison of fish, an account of the eflfects 
produced by eating the murcena conger, the following passage. 
" In the course of the following night, they were all seized with 
violent griping and cholera, together with a peculiar sensation in 
the lower extremities, attended with violent convulsive twitches, 
faintings, &c. They all perceived a brassy taste in the mouth, and 
a rawness of the oesophagus as if it had been excoriated. These 
symptoms continued to afflict the negroes for a fortnight, and then 
terminated in paralysis of the lower extremities. After suffering for 
several months, they recovered with difficulty." 

Are we not here forcibly reminded of what I said in a former 
lecture concerning the connection between enteric disease and 
paraplegia? 

Werlhoff*, as cited by my friend Dr. Autenrieth, in a book* of 
extraordinary ability and research, gave a case where the gadus 
seglesinus, asellus, produced a violent affection of the stomach and 
bowels, together with urticaria. Chisholm relates the same of the 
flesh of the dolphin. Urticaria, diarrhoea, dysentery, paraplegia, 
are said by the same author to be frequently observed in conse- 
quence of eating the flesh of the gray snapper. Forster relates a 
similar train of accidents produced by eating the sparus pargus 
(porgee). In short, I could bring forward citation after citation in 

* Ueber das Gift der Fische. Tiibingen, 1833. 



124 GRAVES'S CLINICAL LECTURES. 

proof of the truth above advanced ; but I am done, for enough has 
been already said to establish the point in question. 

Having established the fact that disease of the digestive organs 
is often intimately associated with urticaria, it remains to prove 
that a similar connection exists between hepatitis — the cause of the 
derangement in the digestive organs (in the case before us) — and 
arthritis. Every one has observed how frequently inflammation 
of the joints becomes in its course complicated with inflammatory 
affections of internal viscera. In general, those viscera whose 
component tissues are most similar to the articular, are the organs 
aflTected. Hence the heart and pericardium are so often attacked 
in the course of rheumatic fevers. It sometimes happens, however, 
although less frequently, that the internal organ attacked has Httle 
analogy in point of tissue with the joints. Thus, in rheumatism, 
and in gout, the stomach, the bowels, the lungs, or the liver, may 
become engaged ; and of these, none, perhaps, so frequently as the 
liver. We need not be surprised at this, when we consider how 
intimately the digestive function is connected with arthritic inflam- 
mation, which is indeed generally preceded or accompanied by 
well-marked symptoms of hepatic and stomach complaints. Indeed, 
almost all medicines that afford relief in arthritis are attended with 
well-marked symptoms of their having acted upon the secretions of 
the ahmentary canal and liver. Thus, colchicum seldom diminishes 
the pain and inflammation of the joints, until it produces copious 
bilious evacuations. 



LECTURE X. 

On bed sores in fever, and their treatment — Instances of fever spreading by contagion 
— Attacking a person whose mouth was affected by mercury — Observations on the 
use of tarter emetic in fever — An account of the manner in which it is usually em- 
ployed — New views upon this subject — Practice first introduced by Dr. Graves of 
giving tartar emetic, combined with opium, in the advanced stages of fever — Success- 
ful cases — Treatment of fever with profuse sweating in the commencement — Mr. 
Cookson's case — Mr. Stephenson's case — Mr. Knott's case. 

I BEG leave to draw your attention to-day to some points con- 
nected with the treatment of fever. The number of fever cases we 
have had of late is much greater than for some years ; and to those 
who are anxious to acquire a knowledge of the phenomena and 
character of one of the most interesting and important of human 
maladies, our wards furnish at present very ample opportunities. 
I trust every gentleman who listens to me will avail himself of such 
advantages, and not permit opportunities of acquiring valuable in- 
formation to pass away unprofitably. It is my duty to speak of 
the particular modes of treatment adapted to fever cases, to inform 
you how each symptom may be most successfully combated, and 
to lay down rules for your guidance in each particular emergency ; 



BED SORES. 125 

it will be your business to collect and arrange the detached nriate- 
rials, and form your general principles with respect to the manage- 
ment of this very important disease. It has never been my wish 
to speak generally of the nature or treatment of fever; time will 
not permit me, nor do I wish to encroach on the province of those 
who lecture on the practice of physic ; my object is merely to note 
symptoms as they rise, to speak of their nature and treatment, to 
confine myself to detached observations, and, as far as lies in my 
power, to contribute facts to those who write or lecture on practical 
medicine. 

A woman has been admitted lately, who had been labouring un- 
der fever for a considerable time before she came into the hospital. 
This poor creature seems to have been in very miserable circum- 
stances during her illness; her bedding must have been totally 
neglected, and no attention paid to cleanliness, for on her admis- 
sion, though nearly free from fever, she was covered with bedsores 
to a frightful extent. Almost every point which had been subjected 
to pressure had ulcerated, and the ulcers went on undermining the 
skin, and committing terrible -devastation in the cellular substance. 
Cases like this require great care and unremitting attention ; it is on 
the exercise of an active and untiring humanity that the cure will 
mainly depend. In the first place, you are to recollect that the 
efforts of the constitution towards the re-establishment of health are 
impeded by the irritation of the sores; sleep is prevented, and the 
patient kept in a state of continual sufl^ering, while a constant drain 
from the system is kept up by the ulcerative discharge, adding to 
the amount of existing debility. Hence a pseudo-febrile state arises, 
characterised by quick pulse, restlessness, and want of sleep, some- 
what akin to that which is produced by scrofulous irritation. The 
appearance, however, of general excitement of the system, should 
never prevent the physician from adopting every mode of strength- 
ening the patient as much as possible. You will not succeed in re- 
moving this condition by an antiphlogistic regimen ; the patient re- 
quires tonics and narcotics, with a nutritious but not stimulatingdiet. If 
you put him on a low regimen, and give anti-febrile medicines, you 
will do mischief; you will increase the existing debility, and add 
to the source of febrile excitement. Your practice should be to 
prescribe a nutritious diet, wine, and the sulphate of quinine, and to 
treat the sores with stimulant applications. The local application 
which we found most beneficial in such cases, is one composed of 
two ounces of castor oil, and one of balsam of Peru, which is to be 
applied on pledgets of lint, and covered with a poultice of linseed 
meal two or three times a day. In addition to this, we direct the 
sores to be washed night and morning with a solution of chloride 
of soda, in the proportion of twenty or thirty drops of the saturated 
solution to an ounce of water. We also direct the patient to lie 
occasionally on her face, and enforce the strictest attention to clean- 
liness on the part of the nurse. Dr. Arnott's hydrostatic bed is an 



126 GRAVES'S CLINICAL LECTURES. 

excellent adjuvant in the treatment of this disease, but unfortunately 
the one we have is at present out of order. 

Such, then, is our mode of treatment. We order the patient 
nourishing, but not heating, food; we give wine, regulating its 
quantity according to its effects on the system, and the liking of the 
patient; we prescribe small doses of the sulphate of quinine, and 
administer an opiate at night to allay irritability, and procure sleep. 
The local treatment consists in the use of stimulant and detergent 
applications, poultices, attention to cleanliness, and change of 
position. 

With respect to the present epidemic fever, we have now seen 
so many instances of its direct communication from one point to 
another in our wards, that we are induced to believe it to be con- 
tagious. From the great number of applicants labouring under 
serious and threatening diseases, we are sometimes obliged to put 
into our fever wards, patients affected with local inflammations, 
accompanied by symptomatic inflammatory fever ; several of these, 
while recovering, have been attacked with symptoms of the present 
epidemic. A man was admitted last week into the fever ward with 
violent pneumonia ; the right lung was extensively hepatised, and, 
in addition to this, the pleura was found to be engorged over a 
large portion of its surface. The case was one of extreme distress, 
and the state of the patient apparently hopeless; however, by ap- 
propriate depletion, assisted by mercury and blisters, convalescence 
became established, and the pulmonary symptoms were rapidly 
subsiding. His system was still under the influence of mercury, 
his fever had disappeared, his dyspnoea was relieved, his cough, 
and all the other symptoms, nearly gone, when he was suddenly 
attacked with fever, and that of the same character as pre- 
vailed among the patients in the same ward. This is, I believe, 
the sixth or seventh case, in which patients labouring under some 
other form of disease, have been seized with symptoms of the pre- 
sent epidemic, while lying in the same ward with fever patients. 
I have thought it necessary to make this observation, because you 
will find it asserted in medical works, and by physicians of con- 
siderable eminence, that in hospitals fever does not spread from 
one patient to another, and that where it does appear among many 
individuals in the same house, its spread is chiefly favoured by 
want of cleanliness and proper ventilation. This, however, we 
can state to be the fact, that fever will spread among patients in 
the same ward, independent of anything connected with filth or 
foul air, for we have seen it occur in our wards, which I can 
assert are kept as clean, and as well ventilated, as any in the 
kingdom. 

There is one circumstance connected with this case worthy of 
remark, with reference to the supposed antifebrile properties of 
mercury. It has been stated that mercury exercises a prophylactic 
influence over the system, and several persons who have cultivated 
medicine with success, but particularly some army surgeons of 



TREATMENT OF FEYER. 127 

high authority, have asserted that the use of mercury not only 
cures fever, but also secures against it. I am afraid that in this 
and other cases, mercury has more credit than it deserves. In 
speaking of cholera, on a former occasion, I have told you that I 
had seen persons under the influence of mercury take cholera and 
die of it ; and here we find a man, whose mouth is still sore, in 
whom salivation had not ceased, getting an attack of fever at a 
time when he had just recovered from another disease. This shows 
that mercury is not to be looked upon as a prophylactic in cases of 
fever of a contagious nature. We cannot always cure or prevent 
fever with mercury; on the contrary, where fever of a particular 
kind is present, it prevents the constitution from yielding to its in- 
fluence. Thus, in a case of hectic fever, brought on by suppuration 
of the liver, it has been found impossible to bring the system under 
the influence of mercury. 

I come now to speak of a matter of great importance in the 
treatment of fever — I allude to the indications for exhibiting, and 
the mode of giving, tartar emetic at different periods of the con- 
tinued fever of this country. For some time I have been in the 
habit of employing tartar emetic with very remarkable success at 
various periods of fever, but principally towards its termination. I 
am therefore anxious to lay before you a brief statement of my 
experience of this valuable remedy, and I shall take leave to illus- 
trate this by a reference to several very remarkable cases in which 
its administration was followed by the most decided and satisfactory 
results. 

You are all aware that tartar emetic has been long and justly 
valued by the profession for its manifold and energetic properties. 
Without referring to its importance in the treatment of pulmonary 
diseases, and almost every form of local inflammation, I may ob- 
serve, with respect to our present subject, that tartar emetic in small 
portions, dissolved in a quantity of whey or water, has been for a 
considerable time a popular and successful remedy in the commence- 
ment of febrile symptoms. Whether it is by its action on the 
stomach and intestinal canal, or by producing diaphoresis, or by 
some peculiar influence on the nervous and circulating systems, that 
it produces its favourable eflects, we cannot exactly say ; but we 
know that it frequently succeeds in cutting short, or removing, 
febrile symptoms. All these matters are, however, sufficiently well 
known to every student, and require no comment. 

In a preceding lecture, when speaking of the best means of pro- 
curing sleep in various forms of acute disease, I alluded to the pecu- 
liar narcotic power of the preparations of antimony, and dwelt on 
the benefits derived from a combinanon of antimonials with those 
medicines which are strictly termed narcotics. I told you* in that 
lecture that the good efl^ects of tartar emetic in delirium tremens 
seems to be totally independent of its action on the stomach ; for we 
had witnessed those efl^ects when it had not excited either nausea 
or vomiiing. I referred also to many instances of delirium tremens, 



125 GRAVES'S CLINICAL LECTURES. 

in which opiorn in every form had failed in procuring sleep, and 
where a combination of tartar emetic and laudanum had succeeded 
in tran: ::";s:nr the patient, and producing sound, refreshing sleep. 
Bea rir.j '...:s inportant fact in mind, we shall proceed to an exa- 
mination of the circumstances which require the use of tartar 
emetic in fever. 

Tnere is a peculiar stage in one form of fever, and that exceed- 
ingly dangerous and threatening, in which I have derived most 
signal benefit from the use of this remedy. A patient, suppose, gets 
an attack of fever, he has all the ordinary symptoms, as thirst, rest- 
lessness, heat of skin, quick pulse, and headache. You are called 
in ahout the third or fourth day, and find that he has all the symp- 
toms I have mentioned still present : his face is flushed, his head 
aching, his pulse from 100 to 110, but not remarkably strong ; you 
find, also, that he has been sweating profusely from the commence- 
ment of his illness, but without any proportionate relief to his 
symptoT!?. and that he is restless and watchful. I'ou are informed 
that . s ri'spi rations are so great that his linen has to be changed 
freqaenijy in the day, and that, notwithstanding this, the pulse has 
not come down, the headache is undiminished, and the patient has 
become more and more sleepless. Here comes a very important 
practical question, namely — How are you to treat such a case? 
The patient has no epigastric tenderness, no cough, no sign of local 
disease in either the thoracic or abdominal cavities : he has been 
purgrf. ;^ed diaphoretics, and perhaps mercurials ; every attention 
'.5 5 :r?n paid to regimen, ventilation, and cleanliness; but still he 
1 cs : ere in a state of undiminished febrile excitement, with per- 
sis.c:/. : radache. quickness of pulse, and sleeplessness. 

In s;: . a case as this you have nothing to expect from the 
sweating : :i ''■]'.'. never produce any relief. I was called some 
time back :•:< se: a vonng gentleman in fever, who was placed in 
sirfi.c ; . :nrs - _;55 ; .:se which I have just detailed. It was 
about tne sisto aay of mis fever, and I found him with a pulse of 
about 110, with considerable restlessness and headache, and was 
informed that he bad perspired profusely from the commencement 
of his illness. On hinting the necessity of more active treatment 
than that which had been employed, his physicians appealed to 
the perspirations as decidely contra-indicating depletion. They 
said that the profuse sweating pointed out the impropriety of active 
measures, and that it was a symptom that would be speedily 
followed by relief. I am convinced that they had taken a wrong 
view of the case, and stated as my opinion that nothing was to be 
expected from the perspirations; that when co-existing with a per- 
sistent febrile condition of the system, when accompanied by quick 
pulse, headache, and restlessness, perspirations always indicated the 
necessity for antiphlogistic measures, and in particular for the use 
of the lancet. I instanced the case of patients labouring under 
arthritis with profuse perspirations not accompanied by relief, and 
said that it was well known that such cases were most successfully 



TARTAR EMETIC IN FEVER. 129 

treated by a full bleeding from the arm. I accordingly stated, that 
although the disease was of five or six days' standing, and the 
pulse not very strong, I would advise immediate bleeding. Sixteen 
ounces of blood were therefore abstracted, with some relief to the 
patient, and without increasing his debility; and it was then a 
question what further steps were to be taken. The young gentle- 
man had been actively purged ; he had no cough or abdominal 
tenderness; his symptoms were headache, sweating, and sleepless- 
ness ; and to these, nervous agitation had now become superadded. 
I proposed here what surprised my colleagues very much, and this 
was, to give our patient large doses of tartar emetic. They said 
the practice was very strange, but consented to give it a trial, on 
laying before them the reasons which induced me to prescribe it. I 
said that in such cases the tartar emetic, forming as it were a part of 
the antiphlogistic treatment which commenced w'ith general bleed- 
ing, would have a tendency to cut short instead of increasing the 
perspiration, by reducing the inflammatory state of the system on 
which it depended. The reasoning seemed rather paradoxical — ne- 
vertheless it turned out to be correct. I ordered the tartar emetic to 
be taken in the quantity and mode in which it is generally pre- 
scribed in acute pneumonia ; that is to say, six grains of tartar 
emetic combined with a little mucilage and cinnamon water in an 
eight ounce mixture, to be taken in the course of twenty-four hours. 
After taking five or six grains, the sweating began to diminish; on 
the second day he scarcely perspired any, and his headache was 
greatly relieved ; he began to improve rapidly in every respect, 
sleep returned, nervous agitation ceased, and convalescence became 
soon established. 

The next case in which I employed tartar emetic with signal 
benefit was one of very insidious character, as many of them are 
at present; they exhibit no prominent or alarming symptoms, and 
yet continue to run on day after day without any tendency to crisis. 
The gentleman who was the subject of this case got an attack of 
fever unaccompanied by any remarkable peculiarity, except that 
he was very nervous, and alarmed about his situation. His fever 
went on day after day without any decided symptom ; he had no 
distressing headache, no cough, little or no abdominal tenderness ; 
there was no vomiting or diarrhoea ; and his pulse was not much 
above the natural standard. He had been leeched over the stomach 
at the suggestion of some medical friends, but this was done rather 
by the way of precaution than for the purpose of combating any 
actual disease. About the eight or ninth day the pulse began to 
rise; he complained of headache, and became restless and watchful. 
On the eleventh day the headache had greatly increased, he was in 
a state of great nervous excitement, and had not closed an eye for 
the two preceding days and nights. This state of insomnia and 
nervous agitation was immediately followed by violent paroxysms 
of delirium ; his eyes, never closed in sleep, wandered from object 
to object with unmeaning restlessness ; his limbs were in a state 



130 GRAVES'S CLINICAL LECTURES. 

of constant jactitation, and he raved incessantly: his voice being 
occasionally loud and menacing, at other times \ow and muttering. 
His friends became exceedingly alarmed, and every remedy which 
art could suggest was tried : — his head was shaved, and leeched 
until they could leech no longer; cold lotions were kept constantly 
applied with unremitting diligence, and he was purged freely and 
repeatedly. At this period, that is to say, about the eleventh day 
of the fever, I was requested by this gentleman's medical friends to 
visit him. On examining the patient, I found that he was con- 
stantly making violent efforts to rise from his bed, and that he had 
a great deal of the expression of countenance which belongs to a 
maniacal patient. Under these circumstances, I advised the use of 
large doses of tartar emetic, in the mode already detailed, except 
that in this case, in consequence of the violence of the delirium, I 
ordered the quantity prescribed for a dose to be taken every hour 
instead of every second hour. The patient took about ten or twelve 
grains during the course of the night, and next day his delirium 
had almost completely subsided. Under the use of the remedy he 
became quite calm, fell into a sound sleep, and began to recover 
rapidly. 

In the two preceding cases I was guided by ordinary principles, 
recognised by all physicians, and according to which the exhibition 
of tartar emetic is recommended in fever whenever there is un- 
doubted evidence of determination of blood to the head, producing 
headache, loss of sleep, and delirium. In the cases which follow, 
tartar emetic was exhibited at a period of fever, and under circum- 
stances that were, with respect to the exhibition of this remedy, not 
less novel than important. The principles which led me to this 
practice have long been established, but nevertheless, the practice 
is entirely new, and (I say it with pride, for it has already been the 
means of saving many valuable lives) it is entirely my own. 

Shortly after the commencement of our present session, Mr. Cook- 
son, a pupil at this hospital, and remarkable for his diligent attention 
to clinical pursuits, caught fever while attending our wards, in 
which many cases of the present epidemic were then under treat- 
ment. His fever was of an insidious nature, not characterised by 
any prominent symptom, not exhibiting any local disease to combat, 
or any tendency to crisis. For the first seven or eight days, with 
the exception of headache, which was much relieved by leeching, 
he seemed to be going on very well; his skin was not remarkably 
hot; he had no great thirst, nausea, or abdominal tenderness; his 
pulse was only 85 ; and he had sweating, which was followed by 
some relief. About the eighth or ninth day the pulse rose, and he 
began to exhibit symptoms of an hysteric character. Now, in every 
case of fever, where symptoms resembling those of hysteria come 
on, you should be apprehensive of danger. I do not recollect hav- 
ing ever met with a single case of this kind which did not terminate 
in nervous symptoms of the most formidable nature. I prescribed 
at the time the usual antihysteric medicines, but without any hope 



TARTAR EMETIC IN FEVER. 131 

of doing good, knowing that these sympton:is were only precursory 
to something worse. I also, as a precautionary measure, had leeches 
applied to his head. The fever went on, the headache became more 
intense, he grew nervous and sleepless, and fell into a state of great 
debility. On the fourteenth day of fever his tongue was black and 
parched, his belly tympanitic ; he was passing everything under 
nim unconsciously; he had been raving for the last four days, con- 
stantly attempting to get out of bed, and had not slept a single hour 
for five days and nights. Dr. Stokes, with his usual kindness, 
gave me the benefit of his advice and assistance at this stage of Mr. 
Cookson's illness, and we tried every remedy which experience 
could suggest. Blisters were applied to the nape of the neck, the 
head was kept cool by refrigerant lotions, the state of the belly at- 
tended to, and, as we perceived that the absence of sleep was a 
most prominent and distressing symptom, we were induced to ven- 
ture on the cautious use of opium. It was first given in the form 
of hydrarg. c. creta, with Dover's powder, with the view of relieving 
the abdominal symptoms as well as procuring sleep. This failing 
in producing the desired eflfect, we gave opium in the form of ene- 
ma, knowing its great power in the delirium which follows wounds 
and other injuries. This was equally unsuccessful with the former. 
He still was perfectly sleepless. We came again in the evening, 
and, as a last resource, prescribed a full dose of black drop, and 
left him with the conviction that if this failed he had no chance of 
life. On visiting him next morning at an early hour, we were 
highly mortified to find that our prescription had been completely 
unsuccessful; he had been more restless and delirious than ever. 
Here was the state in which we found him on entering his chamber 
at eight o'clock in the morning of the fifteenth day of his fever. He 
had universal tremors and subsultus tendinum, his eye was suf- 
fused and restless, he had been lying for some days entirely on his 
back, his tongue was dry and black, his belly tympanitic, his pulse 
140, quick and thready, his delirium was chiefly exhibited in short 
broken sentences and in a subdued tone of voice ; and it was now 
eight days and nights since he had slept. Here arose a question 
of great practical importance. How was the nervous agitation to 
be calmed and sleep produced ? Blisters to the nape of the neck, 
cold applications, and purgatives, had failed ; opium in various 
forms had been"" tried without the slightest benefit ; if sleep were 
not speedily obtained he was lost. At this emergency a mode of 
giving opium occurred to me which I had never thought of before. 
Recollect what his symptoms were at this period: quick, failing 
pulse, black, dry, tremulous tongue, great tympanitis, excessive 
prostration of strength, subsultus tendinum, extreme nervous agita- 
tion, constant muttering, low delirium, and total sleeplessness. I 
said to Dr. Stokes that I wished to try what effects might result 
from a combination of tartar emetic and opium ; I mentioned that 
I had given it in casesof delirium tremens with remarkable success, 
and thought it worthy of trial under the circumstances then present. 



132 GRAVESS CLIMCAL LECTURES. 

Dr. Stokes stated in reply, that he knew nothing with respect to 
such a combination as adapted to the case in question, that he had 
no experience to guide him, but that he would yield to my sugges- 
tion. We therefore prescribed a combination of tartar emetic and 
laudanum in the following form, which is that in which I gener- 
ally employ the remedies in the treatment of delirium tremens :-- — 
E Antimonii^artarizate grana qua! uor, tine t.opii. drachm am, misturae 
camphors, 5viij. Of this mixture, a tablespoonful to be taken 
every second hour. The success of this was almost magical. It 
is true that it vomited him : after taking the second dose he threw 
up a large quantity of bile, but it did him no harm. After the third 
or fourth dose he fell asleep, and awoke calm and refreshed ; he 
began to improve rapidly, and soon recovered. 

The next case to which I shall direct your attention is that of 
Mr. Stephenson, a pupil of Mr. Parr of this hospital. This young 
gentleman, as many of you will recollect, was attacked with fever 
about the middle of January. On Thursday evening he complained 
of languor and malaise, and on the following day felt himself fe- 
verish, but without any prominent or decided symptom. At night 
he took a dose of calomel and antimonial powder, -which had no 
sensible effect, and the following day complained of shivering, vio- 
lent headache, pain in the back, thirst, prostration of strength, and 
sleeplessness. He was ordered to take a combination of tartar 
emetic and nitrate of potash in camphor mixture, which produced 
a few loose stools and some diaphoresis; but in consequence of its 
effect on the stomach, and his complaining much of thirst and epi- 
gastric tenderness, the tartar emetic was omitted, and effervescing 
draughts prescribed. Two days afterwards, the epigastric tender- 
ness siill continuing, twelve leeches were applied over the pit of the 
stomach, followed by blister, which gave relief, and the bowels 
were kept open by enemata. He commenced a second tin-iC the 
use of the tartar emetic and nitrate of potash, with the addition of 
five drops of tincture of opium to each dose, but was obliged to 
give it up again in consequence of the increase in his gastric symp- 
toms. He now became exceedingly restless, and his delirium began 
to assume a very intense character. Leeches were applied behind 
the ears, his head shaved, and his temples blistered: he had also a 
large blister over the abdomen, which gave him considerable relief, 
but the cerebral and nervous symptoms became much worse. The 
delirium went on increasing, accompanied by subsultus tendinum, 
and picking the bed-clothes ; he was perfectly sleepless ; raved in- 
cessantly, and had to be kept down in bed by force. On the 17th 
day of his fever he was in the following condition, — tongue brown 
and rather dry, no remarkable thirst or abdominal tenderness, eyes 
red and ferrety, no sleep for five nights, constant muttering and 
delirium, Jwhich had now assumed the character of delirium tre- 
mens,) subsultus tendinum and jactitation extreme, urine and isces 
passed under him unconsciously. J directed the combination of 



TARTAR EMETIC! IN FEVER. 133 

tartar emetic and laudanum to be immediately given, carefully 
watching its effects. He had only taken two doses when a degree 
of calmness set in, bringing with it relief to all his symptoms, and 
before a third dose could be administered, he fell into a profound 
sleep, from which he awoke rational and refreshed. The mixture 
was continued every four hours with increasing benefit, he slept 
long and soundly, and began to improve in every respect. On the 
second day after he had begun to use the tartar emetic, he took a 
little porter, which was changed the next day for claret and chicken 
broth. In about a week he was able to sit up in bed, and seven 
days afterwards was able to leave the hospital and go to the country 
for change of air. 

The last case to which I shall direct your attention is that of Mr. 
Knott, also a pupil of this hospital, a gentleman remarkable for his 
unremitting attention to clinical pursuits, and from whom I derived 
much valuable assistance in conducting various post-mortem exa- 
minations. This gentleman was attacked with fever about the 
latter part of January, which went on for some time without any 
particular symptom, except considerable restlessness and nervous 
excitement. He then became perfectly sleepless, complained of 
violent headache and thirst, raved, and became exceedingly irritable. 
Opium in various forms and repeated doses, either alone, or com- 
bined with musk and camphor, totally failed in producing sleep, 
and his condition became daily worse. On the 13th day he was in 
a very dangerous condition ; his nervous agitation had risen to an 
alarming height, and for many days and nights he had never closed 
an eye. At this period it appeared obvious that if something were 
not done to calm nervous excitement and restore sleep, he had but 
little chance of life. Under these circumstances I proposed to my 
friend, Dr. M'Adam, who attended with me, to give tartar emetic 
and opium. After he had taken about three tablespoonfuls, he had 
a copious bilious evacuation, and immediately afterwards fell into 
a sound sleep, during which he perspired profusely, and awoke in 
about twelve hours, with every bad symptom gone. The nervous 
irritability was completely allayed; his thirst and headache relieved; 
his tongue moist and cleaning; and his reason quite restored. From 
that period everything went on favourably, and he rapidly gained 
his health and strength. 

Since the foregoing lecture was delivered, I have met with seve- 
ral cases of fever, in which I employed the tartar emetic and opium 
with the same remarkable success. A man named Christopher 
Nowland was admitted into Sir P. Dun's Hospital, on the 3d of 
February last, labouring under fever. He had been ill ten days, had 
raving, subsultus tendinum, and appeared unable or unwilling to 
answer questions. His wife stated that he had diarrhcea for the 
preceding three days, and that he had dozed occasionally, but never 
slept. He appeared exceedingly low and prostrated, and lay con- 
stantly on his back. A succession of flying blisters were ordered 

12 



134 GRA^^ES^ CLEMCAL LECTTRE?. 

to be applied to the chest and stomach, and ~ r e 
piescribed. He 2ilso got the following i ^ 



SpinLsethens oleo^ 5^^ 
.^Miit;. aniBKmie aromatice, 5^- 
Moadii, gr. xuj. — Misce. 

Under the use of these remedies he b^an to recover from his pros- 
tration ; hot as the sleeplessness and deliricm still continued, I 
ordered him to take the tartar emetic mistare in the nsnal way. I 
produced at first two or three fall discharges from the bowels, am 
after he had taken the fourth dose he fell into soond sleep, frc r. 
which he awoke mach better, and soon became convalescent. 

In the case of a patient named lUchael Morrav, who exhibit e 
the same remarkable nervons irritability and sleeplessness, this re- 
medy was also employed with irery striking efiects. This man ha z 
been ill of ferer for ten days before his admission into Sir Patrick 
Dong's Hospital, and appeared so much prostrated that I ordered him 
arrow-root with beer. He raved a httle on the night of his admis- 
sion, and remained withoot closing an eye ontil morning. The 
same symptoms were observed on the following day, and his nerv- 
oos irritability became increased. On the 14th of February he had 
been five days in the hospital, and had not enjoyed a slogle hour's 
sleep. I ordered the tartar emetic mistnre to be given : three doses 
prodoced sleep : he had no other bad symptoms, and recovered com- 
pletely. 

In another very bad ca^of maculated fever, the same resnl:s 
were obtained. The patient, Mary Fannin, had got an attack c : 
fever after a firighL She had been eight days ill at the date :: ' e: 
admission, Febmary 25th. She had irr^nlar pulse, sleeples 5 —5 
headache, and soffiision of the eyes ; moaned and dgfaed cc 
ally, and appeared greatly prostrated. She was blistered, h?. . 
enemata, and took the chloride of soda intemaUy with some benen: : 
but the sleeplessne^ and nervous excitement continued. In :h:s 
case, though the tartar emetic was not followed by speedy conva- 
lescence, still it produced remarkably good efiects; after taking four 
doses of it she fell asleep, and did not awake until next morning. 

There are many other cases which I could adduce to prove the 
value of a combination of tartar emetic and opium in the nervous 
sleeplessness of low fever; the forgoing, however, I trust -will be 
found sufficienL 

I forgot to observe, that all the ca^s I have spoken of as suc- 
cessfully treated by means of tartar emetic combined with opium, 
in the advanced stage of the disease, were ca^s of maculated or 
spotted fever. I shall take a future opportunity of entering more 
fully into a detail of its symptoms. 



SPOTTED FEVER. 135 



LECTURE XI. 



General account of the spotted fever epidemic in Dublin, in 1834-5 — Its most remark- 
able features — Insidious character — Further explanation of the reasoning which led 
Dr. Graves to the discovery of the utility of tartar emetic in its latter stages — Dr. 
Nolan's remarkable case of enteritis, with collapse, cured by enormous doses of 
opium — Cases of singular proportions between the frequency of the pulse and of 
respiration — Case of acute oesophagitis. 

Wheiv I j^st addressed you, I spoke of a very important topic — 
the administration of tartar emetic in the advanced stages of pete- 
chial or maculated fever. A few observations descriptive of the 
present epidemic fever appear necessary. The commencement is 
frequently by no means violent, in proportion to the subsequent 
danger, and the patient often appears merely to labour under the 
symptoms of "a common feverish cold, seldom preceded by violent 
rigors, but attended by a frequently recurring sense of horripilation. 
The pulse, in the very beginning, seldom exceeds 90, and in nearly 
half the cases it falls after a few days to 80, 70, or even lower. 
This slow pulse I observed in many of the pupils, and in all it was 
found to accompany a very tedious and dangerous form of fever. 
Mr. Sangster, Mr. Graves, Mr. Harris, and Mr. O'Flaherty, were 
all so affected ; for none of these gentlemen had a pulse exceeding 
70 in a minute, for many days before the period of the greatest 
danger. In other epidemics similar cases have occasionally oc- 
curred, but in none near so frequently as in the present. When 
the pulse was thus tranquil, the skin was not perceptibly hotter 
than natural, although occasionally a slight degree of the calor 
mordax could be detected. Patients with a slow pulse not unfre- 
quently had little to complain of at first ; for the headache, general 
pains, thirst, and restlessness, generally underwent a notable dimi- 
nution, in consequence of sweating, which came on in the com- 
nnencement — the appearance and the good effects of which were 
well calculated to deceive the practitioner into a belief that the 
fever had terminated. A more accurate examination, however, 
showed that this was not the case ; for the tongue still continued 
much loaded, white in the centre and red at the tip, and the appa- 
rent subsidence of the fever was found to be accompanied by a 
remarkable increase of debility. As the disorder proceeded, a slight 
rash, like ill-defined or suppressed measles, became observable in 
some before the fourth day, but much oftener about the seventh. 
This maculated appearance of the skin increased rapidly, spreading 
over all parts of the trunk and extremities, and in many amounted 
to a well-marked efflorescence of a dusky-red colour: in others it 
was as it were suppressed, and was less obvious, but was still dis- 
cernable by an experienced eye, appearing beneath as if veiled by 
the skin. It was not totally absent in one case out of twenty, 
which occasioned me to name the disease maculated fever. So 
the patient continued, in general, until the ninth, tenth, or eleventh 
day, resting sufficiently at night, with a moderate or even a slow 



136 GRAVES'S CLINICAL LECTURES. 

pulse, some thirst, foul tongue, little or no nausea, epigastric pain. 
or abdominal tenderness of any sort, and, in fact, without a single 
symptom calculated to excite alarm. About this period of the 
complaint, matters began to asume a more threatening aspect ; 
debility manifestly increased : the mind at times was evidcDtly in- 
coherent, particularly after awaking from sleep, and then raving 
during the night ; restlessness : frequent attempts to get out of bed 
not unfrequently supervened in the course of a few days. The 
pulse, meantime, rose very suddenly in many, and continued to le 
frequent during the period of danger. Thus, on the tenth day. 
Mr. Syms's pulse rose from 85 to 120, and so continued until abci:: 
the twentieth day, when improvement commenced. The same 
sudden rising of the pulse took place on the ninth day in Mr. 
]\l'Namara,and he died, on the fourteenth da}^ In others, as I have 
already remarked, the pulse continued tranquil throughout. Thus, 
it was very curious to see a patient with a skin of a natural tern- 
perature, a 'perfectly natural pulse^ tranquil respiration^ clear eye. 
no headache, a soft and fallen abdomen, iritJiout the slightest ti ■ 
dency to epigastric tenderness ; it was vqty curious, I say, to see 
such a patient in a state, nevertheless, of extreme danger, passing 
both fgeces and urine under him : raving, incoherent, or with a low 
mutterinf]j delirium ; subsultus dailv increasing' until it became 
excessive: the greatest possible degree of debility; a dark macular 
efflorescence, and at length total sleeplessness. How many theories 
of fever were refuted by such a case I Usually as the disease con- 
tinued, and when the patient was in a very dangerous state — b'j: 
seldom or never before that — the intestines began to be inflated., 
and the belly gradually became tympanitic: a circumstance of bad 
omen, and which was often the precursor of hiccup. When the 
symptoms did not yield to the efforts of nature or of art, the con- 
gestion of the intestinal n^iucous membrane, indicated b}' these 
symptoms, was soon followed by indubitable evidence of cerebral 
congestion — such as restlessness, suffusion of the adnata, and con- 
traction of the pupils ; this last was the most fatal of all symptom:. 
In two or three cases — as, for instance, that of Mr. Cookson — tiie 
cerebral congestion produced repeated fits of convulsions on the 
thirteenth day, and yet he recovered. The same happened in a 
young woman in Sir P. Dun's Hospital, in whom the convulsions 
occurred on the fifteenth day, and were more violent on the right 
side than on the left, producing strabismus and insensibility of the 
pupil of the affected eye. This girl lost the use of her left side on 
that day, but recovered it on the following ; and eventually, though 
with difficulty, was completely cured. Frequent fits of convulsions, 
affecting the right side more than the left, took place on the seventh 
day in the daughter of a clergyman residing in the Liberty, ana 
were followed by a stupor bordering on coma, which lasted for 
man}^ hours. All these patients were covered with maculae. 

I am thus particular in dwelling on the symptoms manifestly 
denoting a combination of primary general nervous excitement with 
a secondary cerebral congestion ; for, on the successive deve- 



SPOTTED FEVER. 137 

lopment of these states the treatment during the- latter stages 
hinged. I wish you clearly to understand, that, after the headache 
and cerebral excitement which accompanied the very commence- 
ment of the fever had been subdued, or had ceased, after sleep and 
calm had returned, and had continued for many days, then a new 
order of things commenced — subsultus, watchfulness, muttering, 
raving, involuntary discharges, &c. — all denoted great derange- 
ment of the nervous system; but still there was no proof that this 
derangement depended on cerebral congestion. After a few, or 
after many days, however, unequivocal symptoms of the latter set 
in; the face and eyes became suffused and flushed; the pupils 
manifested a tendency to become contracted, and occasionally con- 
vulsions took place; the patient became totally sleepless. When 
the latter and dangerous period of the fever was accompanied by 
the former nervous group of symptoms alone, they yielded to wine, 
musk, porter, and opiates; but when the symptoms indicating cere- 
bral congestion were superadded, then it was that the case assumed 
so great and striking a similarity, so far as the functions of the 
nervous system were concerned, to the well-known variety of deli- 
rium tremens accompanied by cerebral congestion, — to that variety 
of delirium tremens, in fact, which can only be successfully treated 
by the judicious but bold exhibition of tartar emetic combined with 
laudanum.^ It is the discovery of the utility of this practice in 
the advanced stages of spotted fevers, that 1 claim peculiarly as my 
own; for there is not, in the writing of any author on the subject, 
the slightest trace of such a method of treatment to be found. As 
this method has manifestly saved many, many lives, under a com- 
bination of circumstances apparently hopeless, I cannot avoid 
congratulating myself upon being the first to propose a practice 
which has not only diminished the rate of our hospital mortalityf 
in a remarkable manner, but has been the means of saving many 
of my friends and pupils; for, without its adoption, our class at the 
Meath Hospital would have been more than decimated, whereas at 
present we have to regret the loss of but one pupil. 

One word more as to the circumstances under which this plan 

* [This is quite an exaggerated statement'; we have treated several hundred 
cases of delirium tremens without tartar emetic or opium with no loss in the cases 
in which the stimulant treatment was used, and even including those cases in 
which, from the entrance of the patient in a moribund state or from some inatten- 
tion, the treatment could not be tried, the mortality was less than one ;?er cent. 
Cases of this kind, however, require something more than a mere stimulant 
practice ; cupping and purging are often imperatively necessary to relieve the 
inflammatory or congested condition of the brain which accompanies the delirium 
tremens. — Ed.'\ 

f Seventy-three f ever patients — namely, forty-one aslem and thirty-two 
females — were treated in the clinical wards at Sir P. Dun's Hospital during 
the months of February, March, and April. Of these more than fifty were 
cases of maculated or spotted fever, and yet we lost but two females and one 
male. The latter was in a hopeless condition when brought in, and one of the 
former was attacked by varioloid just after the crisis of long-continued spotted 
fever. 

12* 



138 ' GRAVES'S CLINICAL LECTURES. 

was applicable. They were exactly the circumstances which 
formerly would have been believed to demand the fresh application 
of leeches to the head, of cold lotions, and of blisters; for it was 
formerly argued, and justly, we have in this advanced stage of 
fever not merely debility to combat — not merely general nervous 
excitement to overcome — but we have also to contend with cere- 
bral congestion. The latter is the most formidable of the whole : 
let us meet it boldly; let us leech, let us purge, &c., &c. I need 
not repeat to you the details of cases illustrating the ill effects of 
this practice. Suffice it to remark, that you might as well attempt to 
cure delirium tremens with mere leeching, purging, and blistering. 
Observe, I am now speaking of the advanced stages of fever ; for 
where cerebral congestion takes place in the beginning or the 
middle of fever, then is there no room for opium — then will the 
practitioner have recourse to the well-known remedies for active 
cerebral congestion ; viz., purging, leeches, cold lotions, ice to the 
head, &c., &c. In the preceding sketch of the present epidemic, 
many important features have been omitted. The outline is only 
complete in such parts as were required to be filled up for the pur- 
pose of illustrating the principles which directed me in devising 
and employing this new plan of treatment. I shall conclude these 
observations with a few details of Mr. Thomas O'Flaherty's case. 

This young gentleman was seized with the usual symptoms of 
maculated fever, of an insidious character, and not attended with 
any appearance of danger during the commencement of the dis- 
ease. His pulse never rose above 100, and before the seventeenth 
day of the fever, it had fallen to 70, at ivhich it remained during 
the period of greatest danger. The only circumstance which 
excited alarm in my mind, at an early period of his illness, was a 
great degree of mental apprehension manifested in his anticipating 
an unfavourable result, together with a tendency to sleeplessness 
from the beginning. On the tenth, abdominal tympanitis was 
observed, but this was removed in two days by appropriate reme- 
dies. On the twelfth day, he was very restless, and although he 
was perfectly rational in his answers to questions, and did not com- 
plain of headache, nor had flushing of face, or heat of the integu- 
ments of the head, yet he frequently talked incoherently when left 
alone, and towards the latter part of the day began to make repeated 
attempts to get out of bed. On one occasion he succeeded, and 
walked down stairs, from the garret to the parlor. His tongue 
was brown and dry. Under these circumstances, I ordered him 
the mixture containing four grains of tartar emetic and one dram 
of laudanum, in eight ounces of camphor mixture; of this he took 
^ij every second hour. The effects produced by this medicine 
were not very rapid, but still they were decidedly beneficial, for he 
gradually became calmer, wandered less, did not attempt to get out 
of bed, and, during the night, got some sleep. His bowels being 
confined, the mixture was now laid aside, and purgatives exhibited ; 
I should have remarked that the tartar emetic mixture caused pro- 
fuse sweating. On the fifteenth day of the fever, his bowels having 



SPOTTED FEVER. 139 

been acted on, he was ordered twenty drops of Battley's solution 
of opium at night, which produced a comfortable night's rest, the 
first he had enjoyed since his illness. On the sixteenth, the sweating 
continued, belly was fallen, and he was quite rational, but had 
marked subsultus; he got another dose of Battley, but it produced 
no sleep; he had been allowed chicken-broth, beer, &c., for some 
days. On the seventeenth day, the sweating had ceased, and his 
skin had become hot and dry ; great restlessness, constant mutter- 
ing, delirium, subsultus, tremors, picking the bed-clothes, involuntary 
discharges. Porter in small quantities, chicken-broth, fetid injection, 
and twenty drops of Battley at night. On the eighteenth, he was 
reported to have had no stool from the injection, and no sleep 
whatsoever, he answered incoherently, thought his bed was covered 
with lancets, some of which he collected carefully, and reserved 
for me ; belly not tumid, but obstinately confined ; pulse 100. The 
whole of that day, and the following, were employed in procuring 
alvine evacuations, preparatory to again giving opium ; in the mean- 
time, all his symptoms were aggravated, and when I visited him 
on the evening of the nineteenth day, his state was anxioys in the 
extreme, as he had enjoyed no sleep for many days and nights, and 
was in a melancholy state of mental incoherence, raving, tremor^ 
and subsultus. Here came the crisis as to treatment. I remember 
well the time when a patient so situated would have been again 
purged, his head would have been shaved, a few leeches applied to 
the temples, and a blister to the nape of the neck, while perhnps 
wine and musk would ha;ye been exhibited internally. How many 
persons have I seen so treated by the most eminent physicians, 
and how unsuccessful was the practice! To have talked of 
giving opium under such circumstances, and when the marks of 
cerebral congestion were so evident, would have been regarded 
absurd ; my experience on former occasions, however, determined 
me to give opium, and, as the danger was imminent, I gave it 
boldly. To the eight ounce mixture, with four grains of tartar 
emetic, we added one dram and a half of laudanum ; of this he 
took one ounce every second hour, from eight in the evening until 
he had taken five doses. This produced copious sweating ; the 
skin became cooler, he raved less, but still no sleep ; at four on 
the following morning, his pulse became 70, and respirations tran- 
quil ; he got twenty drops of Battley, and at half past five in the 
morning, twenty-five drops more. He had now taken, within a 
short time, about one dram of laudanum, and forty-five drops of 
Battley, combined with nearly three grains of tartar emetic. He 
was tranquil, but did not close his eyes, and muttered occasionally ; 
subsultus less. His pupils now became more and more contracted, 
his eyes less expressive and duller, and when I came at eight in 
the morning, he was evidently deeply narcotised, although not yet 
asleep. I thought that all was lost ;*^ but still, observing the respi- 
ration to be tranquil, and the pulse regular, I indulged a faint hope 
that sleep might still supervene. His eyes now became still more 
inexpressive, the lids gradually closed, his breathing became pro- 



138 GRAVES'S CLINICAL LECTURES. 

was applicable. They were exactly the circumstances which 
formerly would have been believed to demand the fresh application 
of leeches to the head, of cold lotions, and of blisters ; for it was 
formerly argued, and justly, we have in this advanced stage of 
fever not merely debility to combat — not merely general nervous 
excitement to overcome — but we have also to contend with cere- 
bral congestion. The latter is the most formidable of the whole: 
let us meet it boldly; let us leech, let us purge, &c., &c. I need 
not repeat to you the details of cases illustrating the ill effects of 
this practice. Suffice it to remark, that you might as well attempt to 
cure delirium tremens with mere leeching, purgin'g, and blistering. 
Observe, I am now speaking of the advanced stages of fever ; for 
where cerebral congestion takes place in the beginning or the 
middle of fever, then is there no room for opium — then will the 
practitioner have recourse to the well-known remedies for active 
cerebral congestion ; viz., purging, leeches, cold lotions, ice to the 
head, &c., &c. In the preceding sketch of the present epidemic, 
many important features have been omitted. The outline is only 
complete in such parts as were required to be filled up for the pur- 
pose of illustrating the principles which directed me in devising 
and employing this new plan of treatment. I shall conclude these 
observations with a few details of Mr. Thomas O'Flaherty's case. 

This young gentleman was seized with the usual symptoms of 
maculated fever, of an insidious character, and not attended with 
any appearance of danger during the commencement of the dis- 
ease. His pulse never rose above 100, and before the seventeenth 
day of the fever, it had fallen to 70, at ivhich it remained during 
the period of greatest danger. The only circumstance which 
excited alarm in my mind, at an early period of his illness, was a 
great degree of mental apprehension manifested in his anticipating 
an unfavourable result, together with a tendency to sleeplessness 
from the beginning. On the tenth, abdominal tympanitis was 
observed, but this was removed in tvi^o days by appropriate reme- 
dies. On the twelfth day, he was very restless, and although he 
was perfectly rational in his answers to questions, and did not com- 
plain of headache, nor had flushing of face, or heat of the integu- 
ments of the head, yet he frequently talked incoherently when left 
alone, and towards the latter part of the day began to make repeated 
attempts to get out of bed. On one occasion be succeeded, and 
walked down stairs, from the garret to the parlor. His tongue 
was brown and dry. Under these circumstances, I ordered him 
the mixture containing four grains of tartar emetic and one dram 
of laudanum, in eight ounces of camphor mixture ; of this he took 
^ij every second hour. The effects produced by this medicine 
were not very rapid, but still they were decidedly beneficial, for he 
gradually became calmer, wandered less, did not attempt to get out 
of bed, and, during the night, got some sleep. His bowels being 
confined, the mixture was now laid aside, and purgatives exhibited; 
I should have remarked that the tartar emetic mixture caused pro- 
fuse sweating. On the fifteenth day of the fever, his bowels having 



SPOTTED FEVER. 139 

been acted on, he was ordered twenty drops of Battley's solution 
of opium at night, which produced a comfortable night's rest, the 
first he had enjoyed since his illness. On the sixteenth, the sweating 
continued, belly was fallen, and he was quite rational, but had 
marked subsultus; he got another dose of Battley, but it produced 
no sleep; he had been allowed chicken-broth, beer, &c., for some 
days. On the seventeenth day, the sweating had ceased, and his 
skin had become hot and dry ; great restlessness, constant mutter- 
ing, delirium, subsultus, tremors, picking the bed-clothes, involuntary 
discharges. Porter in small quantities, chicken-broth, fetid injections 
and twenty drops of Battley at night. On the eighteenth, he was 
reported to have had no stool from the injection, and no sleep 
whatsoever, he answered incoherently, thought his bed was covered 
with lancets, some of which he collected carefully, and reserved 
for me ; belly not tumid, but obstinately confined ; pulse 100. The 
whole of that day, and the following, were employed in procuring 
alvine evacuations, preparatory to again giving opium ; in the mean- 
time, all his symptoms were aggravated, and when I visited him 
on the evening of the nineteenth day, his state was anxiogs in the 
extreme, as he had enjoyed no sleep for many days and nights, and 
was in a melancholy state of mental incoherence, raving, tremor^ 
and subsultus. Here came the crisis as to treatment. I remember 
well the time when a patient so situated would have been again 
purged, his head would have been shaved, a few leeches applied to 
the temples, and a blister to the nape of the neck, while perhnps 
wine and musk would ha(ye been exhibited internally. How many 
persons have I seen so treated by the most eminent physicians? 
and how unsuccessful was the practice! To have talked of 
giving opium under such circumstances, and when the marks of 
cerebral congestion were so evident, would have been regarded 
absurd ; my experience on former occasions, however, determined 
me to give opium, and, as the danger was imminent, I gave it 
boldly. To the eight ounce mixture, with four grains of tartar 
emetic, we added one dram and a half of laudanum ; of this he 
took one ounce every second hour, from eight in the evening until 
he had taken five doses. This produced copious sweating ; the 
skin became cooler, he raved less, but still no sleep ; at four on 
the following morning, his pulse became 70, and respirations tran- 
quil ; he got twenty drops of Battley, and at half past five in the 
morning, twenty-five drops more. He had now taken, within a 
short time, about one dram of laudanum, and forty-five drops of 
Battley, combined with nearly three grains of tartar emetic- He 
was tranquil, but did not close his eyes, and muttered occasionally ; 
subsultus less. His pupils now became more and more contracted, 
his eyes less expressive and duller, and when I came at eight in 
the morning, he was evidently deeply narcotised, although not yet 
asleep. I thought that all was lost ^but still, observing the respi- 
ration to be tranquil, and the pulse regular, I indulged a faint hope 
that sleep might still supervene. His eyes now became still more 
inexpressive, the lids gradually closed, his breathing became pro- 



140 GRAVES'S CLINICAL LECTURES. 

longed and deep, and at half past eight he was buried in a profound 
and tranquil sleep, which continued for nine hours, when he awoke, 
spoke rationally, said he had no pain in the head, took some drink, 
and fell asleep again. Next morning not a single symptom of fever 
remained. 

I need scarcely observe, that the proportions of the two powerful 
medicines which compose this mixture must, vary according to the 
circumstances of the disease, and the age of the patient. In young 
persons of tender age, the opium must be given in smaller quan- 
tities. 

There is one circumstance connected with this epidemic, but 
which I have also frequently witnessed in other sporadic and epi- 
demic fevers, to which I wish forcibly to draw your attention ; it 
is the existence of tenderness generally over the body, and which 
causes the patient to shrink from the pressure of the finger, applied 
to any part of the integuments. This tenderness arises from an 
irritated state of the nervous system generally, and is usually 
accompanied by severe dorsal or lumbar pain, indicating spinal 
congestion. Now, in a practical point of view, this tenderness 
requires attention ; for if it be overlooked, and if the physician 
applies pressure, in such cases only, to the epigastrium, he will be 
deceived into the belief that the tenderness he there discovers is 
confined to that part, and indicates the application of leeches to the 
pit of the stomach. 

You may observe that I have not yet spoken of the liquor of the 
chloride of soda, a remedy you have seen me order with such re- 
markable advantage in almost all the cases of spotted fever. It is 
my intention to devote an entire lecture to a consideration of the 
nature and properties of this medicine, so successful in the hands of 
myself and my colleague, Dr. Stokes. 

Having spoken so'much of the salutary effects of opium in certain 
stages of fever, it may not be irrelevant to our subject to introduce 
to your notice a remarkable case of violent enteric inflammation, 
attended, as such cases always are when exceedingly intense, 
with cholera-like collapse in the very onset of the disease. This 
case was saved by means of thirteen or fourteen grains of opium, 
given in the course of twenty-four hours, a plan of treatment 
which I first proposed, and which has since been very generally 
adopted. 

I shall take the liberty of reading to you the following letter, 
from my friend Dr. Nolan. 

My Dear Doctor, — The following is an abstract of my notes 
upon the case of my servant Horan : — 

On Monday evening, 27th February last, he casually complained 
of pains in his bowels ; they had not been freed on that day, and 
supposing it an instance of mere indigestion, I ordered him five 
grains of calomel, and a draught of castor oil. For that night I 
heard no more of him, but early on the following morning I was 



ENTERITIS CURED BY OPIUM. 141 

hastily summoned bj one of his fellow-servants, who reported that 
he was dying. I found him labouring under severe but intermit- 
ting pain of the belly, particularly about the umbilicus, violent and 
frequent a^amps, especially in the lower extremities, and occasional 
vomiting. The surface was perfectly cold ; features sunken ; eyes 
surrounded by a dark areola ; voice subdued to a whisper ; pulse 
140, small and feeble ; abdomen tender, though not at all tumid. 
He told me he passed the night in great torture, and that the bowels 
were still unmoved. I immediately ordered ten grains of calomel, 
to be followed in two hours by an oil and turpentine draught, a 
turpentine enema, bathing, &c. 

Three hours subsequently — temperature restored; cramps less 
violent; vomiting less frequent, but bowels obstinate; face and 
pulse equally unpromising as before; abdominal pain increased. 
Was this incipient inflammation? and what is the cure for inflam- 
mation? Bleeding? Well, I did bleed; but scarcely had four 
ounces been taken, when I was very glad to tie up the arm ; the 
prostration alarmed me. Something, at all events, ought to be 
done, and I ordered a sinapism to the abdomen, a repetition of the 
enema (for I confess I have not much confidence in frequent or 
powerful purgatives), a powder, composed of calomel two grains, 
opium quarter of a grain, to be taken every fifteen minutes. 
Towards evening, I thought my patient rallied a little ; his coun- 
tenance was better; pulse firmer; his abdominal pain not increased, 
and he vomited but once ; the injection brought away with it a 
little' mucus, but no more. Repetat haustus terebinth. Repetat 
quoque enema. During the night, there was just a trace of fecu- 
lent matter, but vomiting returned, and I found him in the morning 
(the second of his illness) suffering an increase of pain ; the abdo- 
men, too, was now not only extremely tender, but decidedly 
swollen ; the pulse remained quick and weak as ever. I could not 
discover that he passed water. Would you not call this inflamma- 
tion ? But would you bleed for it? I did, unfortunately, to as 
great an extent as I could, which was about eight ounces, and the 
cadaverous look, the cold clammy surface, in short, the absolute 
collapse which succeeded, and continued for hours, gave me strong 
reason to regret it. It produced no impression upon the pain. 1 
had read with great interest the invaluable observations of yourself 
and Dr. Stokes, as well as the publications of Armstrong, Griffin, 
Gooch, &c., wherein the applicability of opium, to certain modi- 
fications of abdominal inflammation, is forcibly demonstrated, and 
I thought my patient precisely in the condition in which you would 
probably have had recourse to that powerful agent. I, therefore, 
commenced exhibiting half a grain of opium, and two of calomel^ 
every half hour. After the second hour, I substituted for the 
calomel three grains of carbonate of ammonia, which, with the 
opium as before, I continued during the day and the whole night. 
In the morning (the third) I had the satisfaction of ascertaining 
that the pain and swelhng had considerably subsided, and that the 



142 GRAVES'S CLINICAL LECTURES. 

towels had been twice opened: his countenance now spoke pro- 
misingly, and pulse began to fall. I, however, persevered in my 
plan of treatment for the day, and, indeed, for the two following 
nights and days, (gradually increasing the interval between each 
dose, however.) until all trace of pain and obstruction had disap- 
peared. ,The bowels continued to act from time to time, although 
I never ventured upon another purgative: the dejections were at 
first largely mixed with blood and mucus, but soon assumed every 
character of health. Of the sequel (may be the consequence) of 
this interesting case, you most kindly undertook the management, 
and I shall add nothing to this meagre statement o{ facts, which 
Mr. O-Donnell, (of Keane's, in Suffolk street,) to whose humanity 
and care I am deeply indebted, witnessed as well as myself. I 
shall leave you to speculate upon the propriety of bleeding at all, 
under such circumstances. I shall also leave you to decide whe- 
ther the increase of inflammation, which certainly occurred when 
I first gave up the opium plan (on the first night) for the sake of in- 
terposing a purgative, was to be attributed to the change or not. 
May not the case throw some light on the abuse or use of purga- 
tives ? But I am doing more than I intended, and more than is 
useful. 

I remain, my dear doctor. 

Yours most truly, 

J. NOLAX. 

April 19, 1S35. — 10, College Green, 

Let me now return to a subject concerning which I spoke lately, 
viz., the pulse. In the case of a young man named St. Leger, who 
was lately a patient at Sir P. Dun's Hospital, the variation of the 
pulse in difl^erent positions of the body was very remarkable. He 
was just recovering from fever, and exhibited a state of the pulse 
which is not unfrequently observed under similar circumstances. 
During his convalescence the pulse went on declining in frequency, 
until it sank to thirty-six in the minute. When I made him sit up 
in bed, his pulse began to rise rapidly, and, in the space of a minute, 
was at sixty-four. When he stood up it became much quicker, 
hut grew so iceak and indistinct, that it could not he felt at the wrist. 
On applying a stethoscope over the region of the heart, I found that 
its pulsations amount to 112 in the minute. Here is a very remarkable 
difference of pulse depending entirely on change of position. With 
respect to the number of respirations in this young man, I found that 
when lying down they were only fourteen, but when he stood up 
they were thirty. This is a very curious fact, and one which I 
have not before observed. 

In this case, the pulse was very little more than in the proportion 
of two and a half to one, as compared with respiration, whereas it 
ought to be as four to one. We had another case at the hospital, 
in which the pulse was 84, and the respiration 42 in the same time 
in a minute; and a third case, in which the pulse was 120, whilo 



INFLAMMATION OF THE (ESOPHAGUS. I43 

the respiration was only twelve. I have myself seen one case in 
which the pulse was 60, and the respiration 50. 

This variation in the relations which the pulse and respiration 
bear to each other, is principally observed in fever and pulmonary 
disease. I am at present attending a lady in fever, whose pulse 
was 120, and respiration 26, until within the last twenty-four 
hours, since which respiration has increased to 40, but the pulse has 
sunk to 86. Now, is this lady's state improved? Would you 
prefer having her in her present or past condition ? For my part, 
I will say that in such a case I would rather have the pulse than 
the respiration accelerated. A quickening of the breathing in fever, 
without any particular lesion of the thoracic viscera, is always a 
proof that the muscular powers of organic life have been injured ; 
that the diaphragm and respiratory muscles are impeded in their 
functions ; and that the case is of a dangerous character.* 

I do not know any point on which accurate observations are 
more wanting than on the proportion between the pulse and respi- 
ration in various states of the system, and in various diseases. 
Facts upon this subject might be easily collected, and would pro- 
bably lead to curious and instructive results. This would form an 
excellent subject for a monograph, and might be investigated by 
any student who possesses attention and perseverance, and has 
extensive opportunities for observation. Having touched upon the 
change in the frequency of the pulse produced by alteration of 
position, I may here remark that subsequent observations have 
confirmed the validity of the diagnostic mark which I was the first 
to draw from this circumstance in distinguishing functional from 
organic disease of the heart. The general proposition may now 
be considered as established, that in a debilitated person, when a 
sudden change of position makes little or no difference in the fre- 
quency of the pulse, we may conclude that the heart, or at least, 
its left ventricle, is increased in size and strength. 

The following case of acute injiammation of the (Esophagus is 
particularly worthy of your attention, on account of the extreme 
rarity of the disease, and because its symptoms have, for that reason, 
been either erroneously or imperfectly described by authors. 

My friend. Dr. Mackintosh, in his Elements of Pathology, (vol. i. 
p. 228,) observes, " That of all the structures in the human body, 
the oesophagus is perhaps the least liable to disease. In general, it 
is difficult to detect inflammation of the oesophagus till ulceration 
and constriction take place. I have seen only one case of universal 
inflammation of this tube not caused by poison," &c. 

It is no wonder, therefore, that the description Dr. Mackintosh 
gives of the oesophagitis is very imperfect. The same may be said 
of that given by others. The best description of the disease is 
that given by J. P. Frank, in his Epitome. IF I recollect right, 
Abercrombie has recorded one well-marked case of oesophagitis. 
Strange enough, this disease is not spoken of at all in that excellent 
work, the Cyclopsedia of Practical Medicine. 

* The lady referred to died. 



144 GRAVES'S CLINICAL LECTURES. 

The inflammation in the following instance was evidently the 
result of cold, and occurring in a healthy habit, it ran through its 
course in a few days. The case is in the gentleman's own words, 
for when the disease was cured I requested him to give me a short 
account of it in writing. 

" February 24th, 1835. — For some days I felt as if I had caught 
cold, with something like sore throat. I felt as if the root of the 
tongue at the left side was sore. By degrees this extended down- 
wards; a ring about the lowest part of the throat became painful 
on swallowing. The pain was most sensible at the left side. 

26th. — I took a bit of bread before dinner, and, on attempting 
to swallow it perceived great pain from the commencement of the 
throat, proceeding downwards towards the chest, as if the bread 
was then impeded by something, and from thence it seemed to pro- 
ceed with increased pain to the back between the shoulders. I felt 
no want of appetite at dinner, but the attempt to swallow caused 
considerable pain. The night was passed in a state of great rest- 
lessness, and w^ith headache, violent pain sometimes seizing me on 
some little change of position, as it does in lumbago. The pain then 
seemed to atiect the whole chest, and, extending to the back, caused 
a hot, burning sensation directly between the shoulders. 

" 27th. — On attempting to swallow, I felt such pain as to force 
me to cry out as if the entire passage from the throat to the stomach 
was inflamed, and that everything, whether fluid or liquid, had to 
force its way painfully through the passage. In swallowing, it 
seemed doubtl^ul whether the food could proceed.'^ 

So far the details were furnished by the patient himself. In addi- 
tion I may remark that, on the 28th, the inflammation had evi- 
dently begun to diminish, and that in the course of a few days 
more it had entirely disappeared. The treatment was restricted to 
abstinence and antimonial diaphoretics. There was no redness to 
be seen in that part of the throat which is visible when the mouth 
is opened. 



LECTURE XII. 

Persesquinitrate of iron in chronic diarrhoea — Blueness of the fingers and toes in fever 
— Some account of the yellow fever which prevailed in Dublin in 1S27 — Newly ob- 
served affections of the thyroid gland in females — Its connection with palpitation ; 
with fits of hysteria — Erysipelas — Remarks on the formation of acidity of the sto- 
mach in indigestion — Psoriasis — Treatment by arsenic. 

Having lately used, with very considerable success, a preparation 
introduced by Dr. Christison, namely, the persesquinitrate of iron, 
I shall make a few observations here on its properties and use. 

The combination of iron with nitric acid forms a remedy pos- 
sessing tonic, and, at the same time, astringent powers, and hence 
pecuUarly well adapted for the treatment of certain forms of chronic 



CHRONIC DIARRHOEA. 145 

diarrhoea and dysentery. You will be consulted by females of a 
delicate and weakly habit, who frequently exhibit symptoms of 
nervous derangement, such as palpitations, sleeplessness, and 
headache, who are easily excited or alarmed, have a tendency to 
emaciation and paleness, and have little or no appetite. Combined 
with these general symptoms, you find that they have been labour- 
ing under diarrhoea for weeks, and even months, and that this, 
with the other causes of debility, has rendered their condition ex- 
ceedingly uncomfortable. You will also be informed by the patient, 
that she has tried many remedies without benefit, and that she is 
extremely anxious to have something done to give relief; and hence 
it is a matter of importance to be acquainted with any remedy which 
may be likely to prove serviceable in such emergencies. 

It would appear that this form of diarrhoea does not depend on 
an inflammatory condition of the stomach and intestinal canal, for 
the indications of inflammation are absent, such as pain, tenderness 
on pressure, thirst, redness of tongue, and severe or continued 
griping. It would rather seem to be connected with congestion of 
the mucous membrane of the digestive tube of a passive nature, 
and resembling the scrofulous; it is also of an unmanageable cha- 
racter, and very seldom amenable to the ordinary modes of treat- 
ment. The common astringent remedies totally fail ; chalk 
mixture, kino, rhatany root, and catechu, are useless, and in such 
cases it has been observed that opium is generally injurious. If 
you prescribe opium it certainly checks the disease for a time, but 
this temporary relief is accompanied by debility, malaise, restless- 
ness, and many other uneasy symptoms, and the diarrhoea soon 
returns, and is as bad as ever. The medicine which I have found 
most effectual in such cases, is the persesquinitrate of iron, in the 
form recommended by Dr. Christison. With it I have succeeded, 
within the two last months, in curing two cases which had been 
exceedingly obstinate and of very considerable duration, the dis- 
ease having in one case resisted all the efforts of medical skill for 
seven months, and in the other for two years. Seven or eight 
drops of the liq. ferri persesquinitratis, increased gradually to twelve 
or fifteen in the course of the day, was the quantity prescribed in 
both cases. In the course of four days a slight diminution of the 
diarrhoea was perceived, in a fortnight the patient felt much better, 
and in a month or five weeks it had disappeared altogether. This 
took place without being followed by any bad eflfects ; there was 
no swelling of the stomach, no tympanitis, no tormina, no restless- 
ness or nervous derangement; the patients recovered their health 
and strength, and the cure was at once safe and permanent. 

The eflfect of this remedy admits of an explanation on either of 
two grounds. You are aware that nitric acid exercises a very 
powerful influence over many morbid discharges. In chronic 
diarrhoea or dysentery, and in a certain form of diabetes, it is one 
of the most efficient and appropriate medicines which can be pre- 
scribed. We can therefore understand its peculiar adaptation to 

13 



144 GRAYES'S CLINICAL LECTURES. 

The inflammation in the following instance was evidently the 
result of cold, and occurring in a healthy habit, it ran through its 
course in a few days. The case is in the gentleman's own words, 
for when the disease was cured I requested him to give me a short 
account of it in w-riting. 

" February 24th, 1835. — For some days I felt as if I had caught 
cold, with something like sore throat. I felt as if the root of the 
tongue at the left side was sore. By degrees this extended down- 
wards; a ring about the low^est part of the throat became painful 
on swallowing. The pain was most sensible at the left side. 

26th. — I took a bit of bread before dinner, and, on attempting 
to swallow it perceived great pain from the commencement of the 
throat, proceeding downwards towards the chest, as if the bread 
was then impeded by something, and from thence it seemed to pro- 
ceed with increased pain to the back between the shoulders. T felt 
no want of appetite at dinner, but the attempt to swallow caused 
considerable pain. The night was passed in a state of great rest- 
lessness, and with headache, violent pain sometimes seizing me on 
some little change of position, as it does in lumbago. The pain then 
seemed to affect the whole chest, and, extending to the back, caused 
a hot, burning sensation directly between the shoulders. 

" 27th. — On attempting to swallow, I felt such pain as to force 
me to cry out as if the entire passage from the throat to the stomach 
was inflamed, and that everything, whether fluid or liquid, had to 
force its way painfully through the passage. In swallowing, it 
seemed doubtl''ul w^hether the food could proceed." 

So far the details were furnished by the patient himself. In addi- 
tion I may remark that, on the 28th, the inflammation had evi- 
dently begun to diminish, and that in the course of a few days 
more it had entirely disappeared. The treatment was restricted to 
abstinence and antimonial diaphoretics. There was no redness to 
be seen in that part of the throat which is visible when the mouth 
is opened. 



LECTURE XII. 

Persesqninitrate of iron in chronic diarrhoea — Blueness of the fingers and toes in fever 
— Some account of the yellow fever which prevailed in Dublin in 1827 — Newly ob- 
served affections of the thyroid gland in females — Its connection with palpitation ; 
with fits of hysteria — Erysipelas — Remarks on the formation of acidity of the sto- 
mach in indigestion — Psoriasis — Treatment by arsenic. 

Having lately used, wnth very considerable success, a preparation 
introduced by Dr. Christison, namely, the persesquinitrate of iron, 
I shall make a few^ observations here on its properties and use. 

The combination of iron with nitric acid forms a remedy pos- 
sessing tonic, and, at the same time, astringent powers, and hence 
peculiarly well adapted for the treatment of certain forms of chronic 



CHRONIC DIARRHCEA. 145 

diarrhoea and dysentery. You will be consulted by females of a 
delicate and weakly habit, who frequently exhibit symptoms of 
nervous derangement, such as palpitations, sleeplessness, and 
headache, who are easily excited or alarmed, have a tendency to 
emaciation and paleness, and have little or no appetite. Combined 
with these general symptoms, you find that they have been labour- 
ing under diarrhoea for weeks, and even months, and that this, 
with the other causes of debility, has rendered their condition ex- 
ceedingly uncomfortable. You will also be informed by the patient, 
that she has tried many remedies without benefit, and that she is 
extremely anxious to have something done to give relief; and hence 
it is a matter of importance to be acquainted with any remedy which 
may be likely to prove serviceable in such emergencies. 

It would appear that this form of diarrhoea does not depend on 
an inflammatory condition of the stomach and intestinal canal, for 
the indications of inflammation are absent, such as pain, tenderness 
on pressure, thirst, redness of tongue, and severe or continued 
griping. It would rather seem to be connected with congestion of 
the mucous membrane of the digestive tube of a passive nature, 
and resembling the scrofulous; it is also of an unmanageable cha- 
racter, and very seldom amenable to the ordinary modes of treat- 
ment. The common astringent remedies totally fail ; chalk 
mixture, kino, rhatany root, and catechu, are useless, and in such 
cases it has been observed that opium is generally injurious. If 
you prescribe opium it certainly checks the disease for a time, but 
this temporary relief is accompanied by debility, malaise, restless- 
ness, and many other uneasy symptoms, and the diarrhoea soon 
returns, and is as bad as ever. The medicine which I have found 
most effectual in such cases, is the persesquinitrate of iron, in the 
form recommended by Dr. Christison. With it I have succeeded, 
within the two last months, in curing two cases which had been 
exceedingly obstinate and of very considerable duration, the dis- 
ease having in one case resisted all the eflTorts of medical skill for 
seven months, and in the other for two years. Seven or eight 
drops of the liq. ferri persesquinitratis, increased gradually to twelve 
or fifteen in the course of the day, was the quantity prescribed in 
both cases. In the course of four days a slight diminution of the 
diarrhoea was perceived, in a fortnight the patient felt much better, 
and in a month or five weeks it had disappeared altogether. This 
took place without being followed by any bad eflfects ; there was 
no swelling of the stomach, no tympanitis, no tormina, no restless- 
ness or nervous derangement; the patients recovered their health 
and strength, and the cure was at once safe and permanent. 

The effect of this remedy admits of an explanation on either of 
two grounds. You are aware that nitric acid exercises a very 
powerful influence over many morbid discharges. In chronic 
diarrhoea or dysentery, and in a certain form of diabetes, it is one 
of the most efficient and appropriate medicines which can be pre- 
scribed. We can therefore understand its peculiar adaptation to 

13 



148 GRAVES'S CLINICAL LECTURES. 

leeches to those parts in which a change of colour and an impair- 
ment of sensibility appeared to be connected with some obstruction 
in the capillary system. You will recollect that this man's toes 
were better after being leeched, and so far the practice appears to 
be borne out by the result of experience. You should not in such 
cases be led away by the theory of our ancestors, who referred this 
condition of parts to vascular debility. A vast deal has been said 
and written with respect to the state of the capillaries in disease ; 
some say, that to restore the healthy action of a part we must de- 
bilitate ; others that we must excite the capillaries. This point 
has engaged the talents of Dr. Thomson, Dr. W. Philip, and 
several other w'riters, but it still remains undecided, nor do I think 
it can ever be settled. For my own part I am satisfied with being 
able to discover the means of relieving disease, and give myself 
very little trouble about theoretical questions w'hich seem, under 
existing circumstances, to be placed beyond the reach of human 
intellect. In the case before us, the modes which were most suc- 
cessfully employed were leeches, emollient poultices, and fomenting 
the parts with tepid water. 

We do not often witness this blueness of the integuments in the 
fevers of Dublin ; during the epidemic of 1827, however, it was a 
matter of frequent occurrence. That epidemic was also very re- 
markable in many other points of view; it was, if I may so express 
myself, a bad gastro-iyphus. It was a fever in which the chief 
seats of congestion and disease were the stomach and small intes- 
tine ; at the commencement the re-action of the system was exceed- 
ingly violent, but this subsided very quickly, and was followed by 
a stage of awful prostration. The chief interest, however, attached 
to it, arose from the circumstance of its forming a very striking 
link of connection between the ordinary gastric fever of Ireland 
and the yellow fever of warm countries. The phenomena which 
characterised this epidemic convinced me, and every one who wit- 
nessed it, that the common gastro-typhus of this country, and the 
yellow fever of America, Gibraltar, and other places, differ only in 
degree and not in nature. The disease set in with all the usual 
symptoms — violent heat of skin, a quick small pulse, sweating, rest- 
lessness, thirst, nausea, and abdominal tenderness ; this slate of 
things went on for two or three days, and then the patients became 
suddenly and universally jaundiced. The symptoms now began 
to assume a greater degree of malignity; vomiting came on ; a large 
quantity of dark-coloured substance, resembling coffee-grounds, 
was thrown up, and the case most commonly had a fatal termina- 
tion. Here, you perceive, we had yellow fever with black vomit. 
T examined the bodies of about twenty-five persons who died in 
this hospital, and found that the intestinal canal presented an exact 
fac-simile of the morbid appearances described by Jackson, Ban- 
croft, and various other writers on yellow fever. 

In that fever I had frequent opportunities of observing the change 
in the capillaries of the part, which accompanied the appearance of 



YELLOW FEVER. 149 

blueness of the nose. To a person who saw the patient with his 
nose of the natural hue this morning, and found it quite blue on 
the next, the change appeared strange and unaccountable ; but, as 
I spent a great portion of my time in the wards, I had an opportu- 
nity of marking the transition, and detecting the modifications 
which preceded blueness. The part about to become blue became 
altered in a very singular manner. It first became elevated in its 
temperature, but at the same time it grew paler. I cannot explain 
this. Increased heat would seem to prove the existence of increased 
vascularity — fading of colour would seem to prove decrease of vas- 
cularity. Notwithstanding this, these apparently incompatible states 
co-existed; the parts were blanchedj and at the same time felt hot 
to the touch. Where the nose was about to become blue, it first 
assumed a yellowish-white colour, and looked very like a wax nose ; 
in the course of six or eight hours this appearance subsided, and it 
became red ; and after a short time this colour was replaced by a 
purple or dark blue tinge. The same order of phenomena took 
place with respect to the toes, and in a few cases the disease ap- 
peared in the fingers. Such cases were ordinarily accompanied by 
so bad a state of febrile symptoms, that the patients seldom reco- 
vered ; indeed, they died so soon after its supervention, that we had 
no opportunities of observing what course it would take, or how it 
would terminate. The appearance which patients labouring under 
this affection exhibited, was very extraordinary ; they were all 
deeply jaundiced, and the deep yellow of the face made a singularly 
hideous contrast with the indigo blue of the nose.* 

With respect to the vomiting a substance resembling coffee- 
grounds, so frequently observed in this epidemic, I may state that 
it appeared to be identical in its nature with the black vomit of 
yellow fever. You are aware that the matter rejected under such 
circumstances is produced by an oozing of blood from the surface 
of the stomach and duodenum. A quantity of blood is poured out 
from the diseased surface of the mucous membrane of the stomach; 
this remains in the stomach for some time, and coagulates ; the 
secretions of that organ act on it, and change it to a black colour, 
in which state it is thrown up. This is the case in yellow fever, 
and such also was the origin of the black vomit in the fever of 1827. 

I may observe, that in that epidemic, as well as in the present, a 
close inquiry into the history of numerous cases has convinced me 
that the gastro-typhus of this country, as well as the yellow fever 
of warmer latitudes, may arise spontaneously, and be propagated 
by contagion. This, I believe, is a fact which every physician who 
has seen much of fever has not the slightest doubt of. We have 
all repeatedly seen instances of persons catching cold while the 
system was in a relaxed or debilitated state; we have seen^this 
cold followed by violent feverish symptoms, and we have observed 

* The remarkable epidemic fever of 1827 was described in a monograph printed 
by me and Dr. Stokes for the use of the students of the Meath Hospital. 

13* 



150 GRAVES'S CLLNICAL LECTURE& 

these symptoms pass gradually into fever of a typhus character, 

and capable of being propagated by contagion. So many examples 
of this have now occurred, that there can be no doubt that fever 
may arise spontaneously — that it may become in this way sporadic, 
and finally epidemic. At certain periods, it appears to be a matter 
of very little consequence, with regard to the mass of society in 
general, how many sporadic cases of this description may occur ; 
but at other periods, and under a certain state of atmosphere, the 
disease becomes extensively diffused, and assumes the character of 
an epidemic. Here each individual case proves a centre of con- 
tagion^ from which the disease spreads on every side. On the other 
hand, fever may originate spontaneously, assume a tjrphoid charac- 
ter, and yet produce no contagion. ReeoUectiog these circum- 
stances, you will be able to reconcile the conflicting opinions of 
those who have argued so hotly respecting the nature of yellow 
fever; some asserting that it is always contagious — others, never. 
The fact is, that both are right and both wrong; fever may origi- 
nate spontaneously and without contagion, but it may also be pro- 
duced by contagion, and it may, under one class of circumstances, 
run through its course without being communicated to others : 
w^hereas, under a different state of things, each case becomes a 
centre from which the disease spreads on every side. In the pre- 
sent epidemic of maculated or spotted fever, the contagious nature 
of the disease was strongly exemplified — for more than twenty of 
the students, who were in the habit of visiting the fever wards in 
the Meath Hospital, were attacked with spotted fever in the course 
of two months. Although the disease was very violent in many. 
and serious in all, Dr. Stokes and I lost but one of these students : 
we had every reason therefore, to congratulate ourselves on the 
success of the treatment we employed. I shall return to this sub- 
ject hereafter. 

I have lately seen three cases of violent and long-continued 
palpitations in females, in each of which the same peculiarity pre- 
sented itself — viz., enlargement of the thyroid gland ; the size of 
this gland, at all times considerably greater than natural, ws? sur'e:: 
to remarkable variations in every one of these patients. ^^ en . r 
palpitations were violent, the gland used notably to swe.^ a i 
become distended, having all the appearance of being incre?,sed [2 
size, in consequence of an interstitial and sudden effusion :: r ::' 
into its substance. The swelling immediately began to sl .5; e :? 
the violence of the paroxysm of palpitation decreased, arc i ; ; r 
the intervals the size of the gland remained stationary. Its incre: .^e 
of size, and the variations to which it was Hable, had attrac:f :: 
forcibly the attention both of the patients and of their frier.:?, 
There was not the slightest evidence of anj^hing like inflamri.e- 
tion of the gland. One of these ladies, residing in the neighbor- 
hood of Black Rock, w^as seen by Dr. Harvey and Dr. Wil'^arn 
Stokes; another of them, the wife of a clergyman in the county ci 
Wicklow, was seen by Dr. Marsh; and the third lives in Graiton 



AFFECTION OF THE THYROID GLAND. 151 

Street. The palpitations have in all lasted considerably nnore than 
a year, and with such violence as to be at times exceedingly dis- 
tressing ; and yet there seems no certain grounds for concluding 
that organic disease of the heart exists. In one, the beating of the 
heart could be heard during the paroxysm at some distance from 
the bed — a phenomenon I had never before witnessed, and which 
strongly excited my attention and curiosity. She herself, her friends, 
and Dr. Harvey, all testified the frequency of this occurrence, and 
said that the sound w^as at times much louder than w^hen I exa- 
mined tlie patient, and yet I could distinctly hear the heart beating 
when my ear was distant at least four feet from her chest 1 It was 
the first or dull sound which was thus audible. This fact is well 
worthy of notice, and when duly considered appears to favour the 
explanation, lately given by Magendie, of the causes of the sounds 
produced during the heart's action ; for none of those previously 
proposed seem to me capable of accounting for a sound so loud and 
so distinnt. But to return to our subject. The sudden manner in 
which the thyroid, in the above three females, used to increase and 
again diminish in size, and the connection of this with the state of 
the heart's action, are circumstances which may be considered as 
indicating that the thyroid is slightly analogous in structure to the 
tissues properly called erectile. It is well known that no part of 
the body is so subject to increase in size as the thyroid gland, and 
not unfrequently this increase has been observed to be remarkably 
rapid, constituting the different varieties of bronchocele or goitre. 
The enlargement of the thyroid, of which I am now speaking, 
seems to be essentially different from goitre in not attaining a size 
at all equal to that observed in the latter disease. Indeed, this en- 
largement deserves rather the name of hypertrophy, and is at once 
distinguishable from bronchocele by its becoming stationary, just 
at that period of its development when the growth of the latter 
usually begins to be accelerated. In fact, although the tumour is 
very observable when the attention is directed to it, yet it never 
amounts to actual deformity. The well-known connection which 
exists between the uterine functions of the female and the develop- 
ment of the thyroid observed at puberty, renders this affection 
worthy of attention, particularly when we find it is so closely 
related by sympathy to those palpitations of the heart which are of 
so frequent occurrence in hysterical and nervous females. 

Another fact well worthy of notice is that females liable to attacks 
of palpitation almost invariably complain of a sense of fulness, re- 
ferred to the throat, and exactly corresponding to the situation of 
the thyroid. This sensation only continues while the paroxysm of 
palpitation lasts, and frequently is so urgent as forcibly to attract 
the patient's notice, who now complains of its inducing a sense of 
suffocation. Here the interesting question occurs, whether this feel- 
ing of something that impedes the respiration at the bottom of the 
throat, during the hysterical fit, and which has been included under 
the general term globus hystericus — the question arises, 1 say, 



152 GRAVEST CLmiCAL IfiCTIDBEBL 

Mrfaetfaer this feding is always of purely oervoos ©rigiii. To me :. 

appears probable that it is often indnDed by tbe pressure arisirr 
from a sadden enlargement of tbe thyroid, which enlargement su.-- 
sides as soon as tbe fit is over. Of this I am certain, that tbe lamp 
in tbe throat, ot wbicb sDcb females complain, is often exactly re- 
ferred to tbe situation of tbe thyroid : and, indeed, I bave been tcM 
by other practitioners, npon tbe accuracy of whose observations I 
can rely, that this swelling in tbe tbroat of females during the hys- 
teric paroxysm has more than once excited their wonder. It is 
obvious that if palpitations depending on functional disease of liie 
heart are capable of exciting this swollen r 2 : t : :' tlie liiyroid, we 
may expect to observe the tumefaction of i:.:s g i:.a alsfi where tiie 
palpitation depends on organic disease of tbe iieart, as in tbe fol- 
lowing case detailed to me by a frieaad. 

A lady, aged twenty, became afected witb soooe sympton^ wi^^ 
were supposed to be hysterical. This occurred more liian tw: 
years ago; her healtb prenously bad been good. Ahsr sbe Le: 
been in this nerrous state about three montlffi, it was iskBErred thi : 
ber pulse bad become singularly rapid. Tkm rapidity eHsledwiir.- 
oot any apparent cause, and was constant, tbe pnlse being never 
under 120, and often much higher. Sbenext complaiDed of weak- 
ness on exertion, and began to look pale and thin. Tiais she cxm- 
tinned for a year, but during this time she manifest^;:- ':.-t gronnd 
on the whole, the rapidity of tbe heart's action havi:-:: . i e: ceased. 
It was now observed that the eyes assumed a sing:.: . : ; : r :: : : ■. : t, 
for the eyeballs were apparently enlarged, so thai "..r:. 5. r ^.r;:. 
or tried to shut her eyes, the bds were incapable of eiosii^. 
When the eyes were open, tbe white sclerotic could be se^i, to a 
breadth of several lines, all round the cornea. In a few months, 
the action of the heart continuing with unceasing violence, a tii- 
mour, of a horseshoe shape, appeared on the front of the throat and 
exactly in the situation of the thyroid gland. This was at first soft, 
but soon attained a greater hardness, though still elastic. From 
the time it was first observed, it has increased little, if a: ' ■ r : e . 
and is now about thrice the natural bulk of the fully _±"i-:;e; 
gland in a female after the age of puberty. It is somewhat large- 
on the right side than on tbe left. A circumsJaoce wdl worthy : :' 
notice has been observed in this young lady's case;, and which m'cy 
serve to throw some light on tbe nature of this thyroid tumefactic :. 
The circumstance I allude to is, that from an early period of -::.z 
disease a remarkable disproportion was found to exist between tr. :- 
beats of tbe radial and of the carotid arteries, the pnkations of the 
former being comparatively feeble, while those of the latter were 
violent, causing a most evident throbbii^ g{ the necks and accor:.- 
panied by a loud rustling sound. In about fooileen months the 
heart presented all tbe signs of Laennec's passive aneurism ; tr.e 
tumour in the neck is subject to remarkable variations in size. 
sometimes diminishing nearly one-half. None of her family have 



ERYSIPELAS. 153 

had goitres, nor was she ever in any of the usual localities of the 
disease. 

Some time ago, you will recollect, we had a case of erysipelas in 
a young woman, which came on towards the termination of fever; 
a similar occurrence has taken place in a patient in the male fever 
ward. A man who has been for some time labouring under fever, 
got, about two days since, an attack of erysipelas of the scalp, 
spreading downwards over the neck and shoulders. The man had 
been ill of fever of a nervous type, and unaccompanied by any de- 
cided marks of visceral congestion; his condition was to a certain 
extent modified by previous habits of intemperance, but still his 
strength was not much prostrated, nor did he appear to be in a very 
dangerous state. About the fourth week of his illness he gets an 
attack of erysipelas of the scalp, which runs downwards over the 
neck and shoulders, and threatens very dangerous if not fatal con- 
sequences. How were we to treat this case? The man's consti- 
tution, habits, and the period of his fever, contra-indicated depletion 
in any form, and the only thing which we could expect benefit 
from, was the use of sulphate of quinine, which we had prescribed 
in two former cases of this kind with good effects. We gave it 
here, also, in the form of an enema, for the state of the man's sto- 
mach was such as to preclude the possibility of giving it by the 
mouth without hazard. An enema, composed of five grains of qui- 
nine, five drops of laudanum, and two or three ounces of mucilage 
of starch, was injected three times a day. I cannot as yet state 
what the result of this case may be, but the disease is certainly not 
progressing, and the man says he feels better to-day, so that there 
are grounds to hope for a favourable termination. 

Internally I have given the man magnesia with camphor mixture, 
on an empirical principle. It has been stated by some of the older 
writers, that when erysipelas occurs in a weak habit, or supervenes 
on other diseases, that there is an acescent condition of the stomach, 
and that it is on this condition the erysipelatous tendency chiefly 
depends. I have with this view been induced to try the exhibition 
of small doses of magnesia ; I have ordered a mixture composed of 
six ounces of camphor mixture with a dram of magnesia, of which 
the patient is to take an ounce every second hour. 

I may take this opportunity of observing that, since I published 
some remarks in the Dublin Medical Journal, upon the occasional 
symmetrical march of erysipelas at both sides of the median line, I 
have seen other examples of this symmetry. One occurred very 
lately in Sir P. Dun's Hospital, in a woman in whom the point of 
departure for the disease was the face. From this, the erysipelas 
spread over the scalp, and then advanced downwards over the 
neck and shoulders. During its daily progress, I pointed out to 
the students how precisely its outline at one side of the median line 
corresponded with that at the other. This coincidence was the 
more singular, for the boundary of the advancing erysipelas was at 
each side very irregular in form. I think, therefore, that more 



154 GRA^TJS'S CLES'ICAL LECTURES. 

accurate observalioDs on this subject will cause a change of opinion 
in the mind of a learned reviewer in Johnson's Medico-Chirurgical 
Review. 

There is another case, in which I gave magnesia to a man la- 
bouriog under a particular species of indigestion. He had been for 
a long time suftering from chronic rheumatism, and this was com- 
bined with d^-spepsia, characterised by a tendency to supersecretion 
of acid in the stomach, with gastrodynia and sour eructations. In 
addition to anti-rheumatic medicines, and enemata to keep the 
bowels open, we prescribed the subnitrate of bismuth withmagnesia, 
for the purpose of relieving pain and acidity. In gastrodynia, with 
increased secretion of acid from the stomach, one of the best reme- 
dies we possess is the subnitrate of bismuth, with which I am in 
the habit of combining morphia, or, as in the present case, mag- 
nesia. I ordered ten grains of magnesia, twenty of powdered gum 
arabic, and six of the subnitrate of bismuth, to be taken two or 
three times a day, according to circumstai^es : this powder was to 
be followed by a tablespoonful of water, containing one-sixteenth of 
a grain of muriate of morphia. In such cases, if milk does not 
disagree with the patient, you may pour the powder into a quantity 
of boiled milk : allow it to cool, and then stir it with a spoon, and 
make the patient swallow it. The gum arabic is used for its de- 
mulcent properties, and because it enables the patient to swallow 
the powder with more facility : and the fluid in which you mix the 
powder, whether it be water or milk, is to be used warm in order 
to dissolve the gum more speedily. This is a very good combina- 
tion, and I have seen many cases of dyspepsia, with acid eructations, 
which had resisted bismuth, prussic acid, or morphia, given singly, 
yield to it. 

I need not state to you the reasons why magnesia and other 
antacid remedies are given in such cases, but it may be necessary 
to mention briefly the principle on which opiates are prescribed. 
Dr. Elliotson has shown, that many of the morbid states of the 
stomach depend on deranged nervous energy, and that in such 
cases the most efficient means we can use are narcotics. As to 
the subnitrate of bismuth, its mode of action is not very obvious : 
but we know that the metallic salts possess great influence over 
various nervous diseases, as well as over morbid secretions. Wit- 
ness the efi'ects of carbonate of iron, oxide of zinc, the preparations 
of arsenic and antimony, and several others. On this account we 
prescribed the subnitrate, hoping to derive some benefit from its use, 
as well with respect to checking the sour eructations, as to relieving 
the gastrodynia. It may be v/ell to make a few observations in 
explanation of the manner in which tonics and narcotics act in 
diseases of the stomach. Formerly physiologists were of opinion, 
that in weakly stomachs the act of digestion was accompanied by 
the formation of acid and flatulence, because the food being imper- 
fectlv acted on was allowed to under^ro the process of fermentation, 
a process which gave rise to the acid and the wind in the stomachs 



PSORIASIS. 155 

In compliance with this view, physicians endeavoured to procure 
relief in these cases by prescribing a regimen little likely to undergo 
a fermentation capable of causing a production of either air or acid ; 
and they endeavoured to neutralise the bad effects of these, when 
produced by means of the administration of alkaline medicines. 
They used, however, to be astonished at observing that many arti- 
cles of food, which outside the body never formed any acid during 
fermentation, (or more properly putrefaction,) occasioned, never- 
theless, when eaten, as much acidity in the stomach as any other 
aliments. 

It was remarked also by practical men, that although present re- 
lief was obtained by means of alkalies, yet their constant exhibition 
seemed rather to increase than diminish the tendency of the forma- 
tion of acid in the stomach. This fact could not be explained in the 
then state of physiology. In the year 1821, 1 read an essay on this 
subject before the Association of the King and Queen's College of 
Physicians, in whose transactions it was subsequently published. In 
this essay I pointed out the true source of the acidity and flatulence 
observed in dyspepsia, and proved, contrary to the received opinions, 
that it was the result of a morbid secretion. In fact, I showed that 
the stomach has the power, when in health, of secreting acids and 
air, both essentially necessary for the solution of the alimentary 
mass ; and I proved that in dyspepsia this power is morbidly de- 
ranged, in such a manner as to give rise to a supersecretion of acids 
and air. This view of the subject was soon recognised to be cor- 
rect, and, in consequence, new methods of treating dyspepsia w^ere 
proposed. Among the proposals for obviating acidity, that of Dr. 
Elliotson, who recommended prussic acids and other narcotics 
capable of acting upon the nerves of the stomach, (through the 
influence of which secretion is eflfected,) was found to be the most 
successful, and has been sanctioned by the most extensive expe- 
perience. 

Before I conclude, I shall call your attention to the case of Ellen 
Farrow, who has been for a considerable time labouring under ex- 
tensively diffused psoriasis. She was admitted about the beginning 
of last November, and we are now come to the 10th of December; 
so that she has been a patient here for nearly six weeks. Her dis- 
ease is of better than two years' standing, and the eruption covered 
almost every part of the surface of the upper and lower extremities, 
the trunk remaining unaffected. The patient, you perceive, is a 
fine healthy country girl, and though the complaint has lasted so 
long, her system does not seem to be in the slightest degree im- 
paired, appetite, digestion, and sleep are perfectly good. Now, on 
examining her soon after her admission, you will recollect that I 
told you that the duration of the disease, the absence of constitu- 
tional irritation, and of irritation in the parts affected by psoriasis, 
all contra-indicated a mode of treatment which frequently proves 
highly useful, namely, the antiphlogistic. If called to a case in 
which the disease was recent, and attended with heat of skin, red- 



156 GRAVES'S CLINICAL LECTURES. 

ness and itching, I would bleed, leech the affected parts, and put 
the patient on a spare diet. Even in some cases of a chronic cha- 
racter, this treatment may be employed with great advantage. 
Here, however, the state of the patient was such as not to require 
antiphlogistics, and accordingly we put her on the use of Fowler's 
arsenical solution. By the way, when you give this remedy in 
private practice, where patients or their friends are very curious in 
scanning your prescription, you may, in order to prevent alarm, or 
have the action of the medicine interfered with, write on your pre- 
scription — " Liquor minei'alis Fowleri/' 

I mention this case of Farren's chiefly for the purpose of showing 
the extent to which the arsenical solution may be carried. Mind, 
I do not mean to boast of the quantities of medicine my patients 
swallow. Some persQiis appear to think that there is something 
very brilliant in prescribing enormous doses: I should, however, be 
very sorry to make such experiments. Arsenic is a very powerful 
remedy, and its effect on diseases of the skin can be amply secured 
by moderate doses ; where these fail, it is very often from not con- 
tinuing the use of the remedy for a sufficient length of time. Lat- 
terly this girl has been taking ten drops of Fowler's solution three 
times a day, and, as she is getting well, I do not intend to increase 
the dose. We began with three drops three times a day : after a 
few days this was increased to five, and then lo seven drops three 
times daily. She then began to take ten drops three times a 
day ; but after a few days having got an attack of shivering, fol- 
lowed by symptoms of feverish excitement, and herpes labialis, we 
stopped the arsenic for five days, and then began to give it again 
in small doses, which were gradually increased until we came to 
the quantity she is taking at present. Whenever you have a patient 
under the use of arsenic, you must never omit making daih^ inqui- 
ries as to the state of the head and stomach ; if the patient com- 
plains of gastrodynia or nausea, if there be pain or giddiness of head, 
or if, these being absent, a state of feverishness or general nervous 
excitement supervene, it is a proof that the remedy has been pushed 
sufficiently far, and under such circumstances you should suspend 
or give up its employment. In this case, being unwilling to give up 
the use of arsenic, as it appeared to be curing the patient, I merely 
suspended it for a few days, and then had recourse to it again. In 
order, however, to prevent it from acting unfavourably on the sto- 
mach, I have latterly prescribed it in the following form : — 

R Liq. arsenicalis, tt^ x. 
Aquae distillatae, gj. 
Tinct. opii, tt^ x. 
Spirit, lavandulae, compos. 5iss. — ft. haust. 

This appears to agree very well with the stomach ; and as she is 
improving very rapidly, I intend to continue it for some time with- 
out increasing the dose. 

The only other point worthy of remark in this case is, that we 
observed in it a phenomenon connected with the state of the skin, 



DYSENTERY. 157 

such as usually occurs when a patient is using sulphur or sulphur- 
eous waters for the cure of chronic cutaneous affections. After 
they have been taking these remedies for some time, they expe- 
rience a slight exacerbation of symptoms, and complain that the 
eruption is growing worse. This, however, should never induce 
you to give up the remedy without further trial ; for this temporary 
ago^ravation generally precedes the disappearance of the disease. 

We dismissed a case of dysentery lately from our wards, con- 
cerning which I promised to make a few observations. During the 
months of August and September last, we had in Dublin several 
cases bearing a decided analogy to the dysentery of Cullen. There, 
were fever, griping, tenesmus, a constant inclination to go to stool, 
without being abfe to pass anything but a little mucus and blood, 
and occasionally scybala. In this form of disease, some authors 
are inclined to attribute all the bad symptoms to the presence of 
these scybala, which are small hard lumps of fsecal matter, evi- 
dently formed in the sacculi of the great intestine. You will find 
others asserting that this cannot be the case ; for in many dysen- 
teries there are no scybala at all, and that, even when they do occur, 
they have no connection with the disease. The latter take no ac- 
count of scybala, while the former state that the diseased condition 
of the intestine depends upon the irritation produced by them, and 
that you never can expect to cure the disease without getting rid of 
them by active purgatives. For my part, I believe that there are 
certain dysenteric states of the great intestine, in which the main 
cause of the disease arises from the lodgment of quantities of hard, 
unhealthy, and long retained feecal matter ; but in cases of epi- 
demic dysentery, I do not think that scybala have anything to do 
with the formation of the disease, or the aggravation of its symp- 
toms. 

In the present case, the aflfection appears to have been pure rectile 
dysentery, depending almost exclusively on inflammation of the rec- 
tum, not extending to the sigmoid flexure of the colon, and certainly 
never as far as its arch. The symptoms present were fever, in- 
creased heat of skin and quickness of pulse, with a feeling of heat 
and pain in the situation of the rectum ; for the first day the dis- 
charges consisted of mucus and blood, combined with fsecal matter, 
but after this the mucus and blood vi^ere voided alone with great 
griping and tenesmus, and the patient was obliged to get up to the 
night chair thirty times in the course of twenty-four hours. There 
was, however, no symptom indicating that any portion of the intes- 
tine beyond the rectum was affected. Now, what was the con- 
sequence of this state of things ? The inflammation of the rectum 
gave rise to constant spasm of that organ; the colon partook more or 
less in its spasmodic action, and hence every attempt to pass the 
stools was resisted. Here, however, the f^ces lay in a portion of 
the intestine free from inflammation ; they could not produce any 
aggravation of the symptoms, and the scybala were to be looked 
on as the consequence and not the cause of the disease. Now, whe- 

14 



158 GRAVESfS CLENICAL LECTUEE& 

tber purgatives were given by iDJection, or by the month, they 
wooid have done no good in such a case as this; we might have 
copious faecal discharges, but without the slightest diminution of the 
local symptoms. I do not mean to say that there are not dysente- 
ries in wluch purgatives are highly useful, but in the case before us, 
where the disease was limited to the rectum, I did not think that 
any benefit could be derived from them. I confined my attention, 
therefore, entirely to local means directed to the part inflamed, ap- 
plied leeches to the anus, gave narcotic and emollient enemata, and 
after I had in this way relieved pain and irritation, I combined with 
the enem)ata, first, a small quantity of the acetate of lead, with the 
view of restoring the tone of the relaxed mucous membrane, and 
afterwards changed it for the sulphate of zinc. Under this treat- 
ment the case went on very favourably, and we have been able tc 
dismiss the man in a very short space of time. 



LECTL'RE XIII. 

Case of loDg contiBiied nenrans {erers ; rtoDarks oa — ■Pki:r>-pi:e^ii30Bia — Cases of 
latent iJranisy ; of pneomoi^ia — pithisis : kitBt ■olserauan of the zowels m — Diar- 
ihceaof plithms — Ob9CTvalion.5 cii tie stin^raerkir of para'v^c perscE-s — Ib expiJa- 
nalioD — Vray remaikaUe case of smue-rmz cored bj chronic laiy agitis — TneaSmcnt 
oihomaaieas — Yetpean^s nesr rnddiod of treatoDg soie duoaL 

Permit me to make one or two observations on a case of which 
I have already spoken, and which, as I expected, has teqninatec 
fatally. A man, named Lynam, has been lying ill for a long time 
in the large fever ward ; I wrote at the top of his card •* Hervous 
Fever,^ and remarked to the class, that his disease was pure fever 
of a nervous type, unaccompanied by any symptoms indicating 
decided local inflammation. You will recollect that his symptoms 
were heat of skin, quick, weak, compressible pulse, thirst, watch- 
fulness, and low muttering delirium, unattended by any apprecia- 
ble sign of visceral disease, or any symptoms denoting a putrescent 
state of the fluids. It was not congestive or putrid, or gastro- 
enteric, or petechial fever ; neither could it be called a cerebral 
fever ; it was only by separating firom it the idea of each of these 
species, and by studying its negative characters, that you could 
arrive at something hke an accurate conception of the type of the 
disease. It was, as I have already stated, nervous fever, modified 
by the patient's previous habits of long continued intemperance. 
When a patient, addicted to intemperate habits, gets an attack of 
fever from cold, fatigue, or exposure to contagion, you wiU gene- 
rally find the disease will exhibit a compound or mixed character, 
the phenomena of fever being combined with those of defirium 
tremens. And so it was in this case ; the man had general tremors, 
with persistent watchfiilness, and muttering delirium. 



NERVOUS FEVER. 159 

His treatment consisted in the employment of medicines calcu- 
lated to soothe the nervous system, and I kept a constant watch 
over the state of the principal viscera. About a week after he came 
under my care, and about five weeks from the commencement of 
his fever (for he was nearly a month ill before he came to the hos- 
pital), he was attacked with erysipelatous inflammation of the face 
and scalp. The disease commenced on the face, and, traveling 
upwards, very rapidly attacked the whole scalp and back of the 
neck, its progress being accompanied by great aggravation of 
symptoms. At that time I remarked to the class that I did not en- 
tertain any apprehensions of a metastasis of the erysipelas, that I. 
had no fears of the supervention of inflammation of the brain, and 
its train of alarming consequences ; but that no good vii'as portended 
by this attack of cutaneous inflammation, and no relief of the in- 
ternal parts could be expected from it, for every symptom appeared 
aggravated from the moment that the erysipelas commenced. I 
pointed out the total inadmissibility of anything like vigorous or 
antiphlogistic treatment, in a case where the disease had appeared 
in an individual of broken constitution, labouring under a combi- 
nation of delirium tremens with low fever ; and said that even the 
remedy which we had found most successful in similar cases, 
namely, sulphate of quinine and opium, offered but a feeble hope 
of arresting the malady. It failed, as we expected, and the man 
died yesterday, worn out by long suflering and exhaustion. Eigh- 
teen hours after death we made a most careful examination of all 
the viscera of the three great cavities ; not a single organ exhibited 
the least mark of inflammation ; we could not find anywhere even 
the slightest trace of local congestion. The man had all his viscera 
in an apparently sound and normal condition, and died of pure 
nervous fever. 

Some persons look upon the existence of fever independent of 
topical affections as purely imaginary, and deem those, who have 
recorded such forms of disease as too ignorant, or too lazy, to 
make the necessary pathological investigations. I have not time 
at present to enter into this subject, but of nothing am I more con- 
vinced than that fever may exist without any appreciable local 
lesion, that it may affect every organ and every tissue of the body 
ahke, and yet that the most accurate symtomalologists cannot lay 
his finger on any one single part and say, here is local inflamma- 
tion of a decided character. I have met with many instances con- 
firmatory of this fact in hospital practice. I recollect a case which 
occurred some time ago at this hospital, which was equally remark- 
able for its extraordinary duration, as for the total absence of any 
thing like visceral lesion. The patient was admitted into the small 
fever ward, labouring under an attack of nervous fever ; he " had 
thirst, hot skin, pulse from 110 to 120, occasional delirium and 
watchfuhiess, and these symptoms went on week after week, and 
month after month, unaccompanied during the whole course of the 
disease b}^ any phenomena indicating the existence of local inflam- 



160 GRAVEST CLIOTCAL LECTURES. 

matioD. H:5 .. t t ! was purely expectant and temporising : we 
had no ce ^ :!. or thoracic lesion to combat; there 

was no cr; afebrile derangement could be said to 

have fisei :v ei^jusiveij, no threatening disorganization calling 
for the profijy; eajplojment of new and energetic means. At last, 
after the fever had continued for very nearly three months, the man 
complaining all the time of more or less thirst, hot skin, watchful- 
ness, and headache with occasional delirium, the disease termi- 
nated in a well marked crisis, accompanied by sweating. He fell 
asleep, began to perspire, awoke with a pi]lse nearly reduced to 
the natural standard, and perfectly recovered. I may observe that 
I have never seen fever last so long as this, nor have I ever observed 
a perfect crisis in any case after the forty-second day. Some time 
ago I attended the brother of a gentleman now present, who had 
a long and very severe attack of fever ; though he never had a 
remission during his illness, and was in very urgent danger, he got 
a perfect crisis with profuse perspiration on the forty-second day. 
and is now in the enjoyment of excellent health. 

You perceive, then, that the case of Lynam presents some cir- 
cumstances worthy of notice. His fever went on to its terminafior. 
without any symptoms of inflammation in any viscus, and his actual 
condition, as carefully ascertained by an accurate post-mortem 
examination, affords a useful lesson to the pathologist. His case is 
also interesting in showing how previous habits will modify, in a 
remarkable degree, the character of fever ; for in him you have 
seen fever combined with the phenomena of delirium tremens, a 
state of things which it was natural to expect in a man of extremely 
intemperate habits. The termination of the erysipelas without 
any sign of disorganization within the cranium is also wonhy of 
notice. In such cases you have it frequently followed by inflam- 
mation of the brain and its membranes, and an exudation of pus 
on the surface of one or both the hemispheres ; but here you per- 
ceive that there has been no extension of the disease, or nothing 
that should have induced us to give up the plan of treatment we 
adopted, and direct our therapeutic means to the head. 

Let me now direct your attention to another topic. You have 
seen that a principal feature in the character of the present pneu- 
monia is its complication with pleuritis ; we have had several cases 
of inflammation of the lungs, combined with inflammation of their 
investing membranes, but I do not recollect that we have had a 
single case of pure pleuritis, or pure pneumonia. In the patient 
who lies at present in the chronic ward, labouring under pleuro- 
pneumonia, the inflammation occupied the superior part of the 
right lung in the first instance, and this is rather remarkable, as 
pneumonia generally commences in the lower part of the lung. 
Here, however, the pneumonia and pleuritis were located above, 
each being in point of extent nearly of the same dimensions, the 
portion of inflamed lung corresponding in its area to the portion 
of pleura engaged io the disease^ Soon after bis admission we 



PLEURO-PNEUMONIA. IGl 

found that the inflammation was making further progress, but its 
spreading was attended with this remarivable peculiarity, thatfwhile 
the pleuritic inflammation in the superior part of the right side of 
the chest became hmited and ceased to extend itself, the pneumonic 
inflammation commenced traveling downwards and backwards, so 
that after two or three days we had pleuro-pneumonia in the upper 
part of the lung, and further down in the lower and back part of 
the lung it was merely pneumonia unaccompanied by pleuritis. 
This is an occurrence which I have frequently witnessed, that when 
pleuritis and pneumonia co-exist, the latter will spread, often in 
spite of all our eflTorts, while the former remains stationary. I 
wish to impress this fact on your minds, that pleuritis never exhibits 
such a tendency to extend itself gradually, day after day, as pneu- 
monia; if the pleura becomes inflamed, the extent to which it is 
likely to be engaged will be determined in twenty-four hours ; 
whereas, in cases of pneumonia, the disease, though limited at the 
commencement to one or two small insulated spots, will frequently 
begin to extend in every direction from these points, until in the 
course of a few days it involves a large portion of the lung. In 
other l^ses, many days are required before the spreading of pneu- 
monia ceases. 

This case is of considerable interest to the stethoscopic student, 
as exhibiting in a very satisfactory manner all the physical signs of 
pneumonia, as well in its pure state as where it is complicated with 
pleuritis. It is unnecessary for me to enter into any detail of the 
symptoms or of the physical signs, but I invite you to study them 
as well worthy of your attention. 

A patient has recently died, who came into hospital labouring 
under a disease which generally proves fatal, namely, double 
pleuro-pneumonia. He had violent pleuritis and pneumonia in 
both sides of the chest under these peculiar circumstances ; that in 
the left side the pneumonia was situated above and anteriorly, in 
the right side below and posteriorly ; so that the lungs were affected 
nearly at the opposite ends of their transverse diameters. On his 
admission, he appeared extremely low and weak, and it was 
obvious that the case must term.inate fatally. His respiration was 
extremely quick and laboured ; he had great oppression about the 
chest, constant anxiety, incessant harassing cough, quick weak 
pulse, and a countenance expressive of intense suflering. On exa- 
mining the chest with the stethoscope, we found that both lungs 
were extensively solidified ; and this, combined with his age, and 
the manifest sinking of the powers of life, prevented us from indulg- 
ing in any hope of being able to arrest, much less to remove, his 
complaint. He was a poor creature, moving in the very lowest 
class of life, ill-fed, without sufiJicient clothing, most wretchedly 
lodged, and constantly exposed to cold and hardships. He had 
been employed in breaking stones on a road at fourpence per day, 
and out of this miserable pittance endeavoured to maintain a family. 
From repeated exposure to inclement weather, he got a violent 

14* 



164 GRAVES'S CLINICAL LECTURES. 

senilis ; I shall introduce a probe and lay it open. Here is the track 
of this fistulous opening, and you perceive it terminates in one of 
the large ramifications of the left bronchus. You may perceive, 
also, that the section I have made displays masses of small granular 
tubercles in the upper and anterior portion of the lung, quite difl^er- 
ent in size and appearance from the large tubercles seen in the child 
and adult. I shall now make a section of the right lung. It is 
much more natural in its feel and appearance than the left, but still 
in all chronic cases of phthisis we seldom have the disease limited 
to a single lung. Hei'e you perceive are a few patches of granular 
tubercles, looking as if they were infiltrated into the substance of 
the lung, and not surrounded as the large tubercles of the adult and 
child are, by vascular condensed pulmonary tissue. Here, you see, 
1 have cut into a small cavity; from its contents and appearance, 
you can judge that it is of comparatively recent formation; it has 
no semi-cartilaginous lining, and is of very inconsiderable size. 
You perceive, also, that it communicates freely with a pretty large- 
sized bronchial tube, and contains a quantity of muco-purulent 
secretion. 

With respect to the state of the viscera of the abdomen, I may 
observe, that with the exception of some portions of the intestinal 
tube, which I am about to show you, they presented nothing very 
remarkable. The liver and kidneys were found to be of the natural 
size, somewhat indurated, and very friable, and the spleen exhibited 
several small tubercular spots on its surface. Here are the stomach 
and duodenum, which you perceive retain their normal appearance ; 
and the same remark is to be made of the colon and rectum. Iq 
the ccecum, however, which you see here, and here also in the 
ilium, there are several ulcerated patches of an oval form, and cor- 
responding to the situation of the glands of Peyer. In some places 
you perceive the ulcers have destroyed not only the mucous mem- 
brane, but also the muscular coat of the intestine, and have very 
nearly produced perforation. 

A most important inference may be drawn from this fact. Here 
we have several ulcers, destroying the mucous coat of the intestine, 
and eating their way through its muscular tissue, so that the only 
barrier left to prevent an efi:usion of the intestinal contents into the 
cavity of the peritoneum, is a thin layer of serous membrane. Yet, 
during the whole time he remained in the hospital, his bowels were 
so obstinately costive, that we were .obliged to give him purgative 
medicine every second or third day, to procure an evacuation. 
You would suppose, a priori fih?it a man, in whom ulceration of the 
bowels existed, would suffer considerably from pain, griping, and 
tympanitis, and that he would labour under the diarrhcea so fre- 
quently observed in the advanced stage of phthisis. Our prede- 
cessors entertained a notion that the diarrhoea of phthisis is a species 
of internal sweating; they observed, that when the patient ceased 
perspiring from the skin, he was generally attacked with a watery 
diarrhoea, and hence they termed The diarrhoea colliquative. After- 



I 



ULCEKATION OF THE BOWELS. 1G5 

wards it was found, on numerous examinations, that where this 
diarrhoea had existed, there was in most cases ulceration of the 
bowels; hence pathologists began to believe that this ulceration had 
a great deal to do with the intestinal symptoms observed towards 
the termination bf phthisis, referring to it the abdominal pain and 
tenderness, the unmanageable character of the diarrhcea, and the 
aggravation of the hectic symptoms. 

Now it strikes me that this mode of accounting for these symp- 
toms was, perhaps, too hastily adopted. No doubt ulceration of the 
bowels may produce all the symptoms detailed ; but, on the other 
hand, it may exist to a very remarkable extent, and yet produce no 
symptoms by which it could be recognised. Here was a patient 
who never had the slightest tendency to diarrhoea, who never com- 
plained of pain, griping, flatulence, or abdominal tenderness ; on 
the contrary, his bowels were not merely slow, but even confirmedly 
costive, and he always felt more or less relief from the use of pur- 
gative medicine. None of us ever suspected that anything like 
ulceration existed ; we gave him a full dose of castor oil every 
second day, which produced one rather scanty evacuation, and yet 
when we come to examine his intestines, we find numerous patches 
of ulceration. This case is calculated to make a deep impression 
on every reflecting mind ; in a practical point of view, it is of great 
importance. If the scrofulous disease had in this case been entirely 
limited to the bowels, and had not touched the lung, the great pro- 
bability is, that it would have been almost wholly latent ; that the 
man would have taken no notice of it, would have thought himself 
w^ell, and eaten, drunk, and worked as usual; that the disease 
would have gone on stealthily committing its ravages, and that 
one of the first symptoms of danger would have been the occur- 
rence of perforation, followed by universal and fatal peritonitis. 
The question would then be as to the cause of death. The patho- 
logist would open the body, and find at once that the cause of the 
whole mischief was ulceration of the intestines; but he would be 
mortified to think that the work of destruction had gone on silently 
and unobserved, and that it could not be recognised until a new 
disease appeared, under which the patient sank. 1 have read of 
more than one case in which a person killed by accident was found 
to have large ulcerated patches in the ih'um, and yet had not been 
known during life to complain of any intestinal symptoms. In 
one case, a strong and apparently healthy Lascar, who had eaten 
heartily an hour before he was killed, and whose digestion was, 
according to his friends' account, unaffected by any morbid de- 
rangement, presented, on examination, a number of deep ulcers in 
the ilium, which would in all probability have ended in perforation 
and peritonitis in the course of a few days.* 

* [In these cases the distinction between follicular and common inflammation 
of the bowels should not be forgotten. If the membrane be affected, the symp- 
toms of diseased bowel are much more permanent than if the follicles only be 
inflamed, or even ulcerated. It is true, that acute inflammation is more often 



166 GEATES^S CLINICAL LECTUEEa 

At the csoQclEmem of this lecture I intend to speak of hoarseness 
and chroBic ianrngitis, and shall most probably return to this inte- 
restiiig tc^pic again. At present I shaB detain jou for a lew moments 
with a brief outline oi a case of total loss of voice, which I hare 
lecenOj witnessed, and -which is in itself so singular that I fr"!-:e 
DO apok^y for ginng it. 

Before I mentkm this case, allow me to observe that loss oi' speecii 
arises sometimes from lemons of apparently a very trifiing charac- 
ier. A p^Bon may totally lose his speech without any previously 
existing or premonitory symptoms indicative of nervous lesion — 
witbonit haiing experienced anj sensation of pain or vertigo, any 
noise in tbe ears, any indications of determination to the head — in 
iact, witluNit anythu^ to ^low that the aphonia was connected 
wilfe any particoiar state of tbe brain. Thus, a barrister, whom I 
attended witb Dr. Beatty, was walking- op and down the hall of the 
Four Coart% waitii^ for a cai^e to come on, and chatting with one 
£ri^id and another; as the ball was rather crowded and hot, he 
went out into tbe area of tbe coorts for th i :' tiie air, and had 

not remained there more than ten nunntes :i : ..ii old friend from 
the country came op and spoke to him. He was pleased to see hi? 
fneod. and wished to inqoire about his family, when he found, to 
bis greal surprise, that be coaM not otter a single audible sound ; 
he had completdy lost his voices He recovered the use of his 
toogoe in about three weeks, hot not completely, for some slowness 
of speech remained. When the loss of speech was first perceived, 
bis firiend brought him home in a carriage ; and during the day he 
bad several attai^ of vertigo, and afterwards hemiplegia. For 
several hours; however, b^ore distortion of tbe face or any of the 
osoal symptoms of paralysis had commenced, the only existing 
symptom was loss of sp^ch. This gentlemaa died of apoplexy 
in aboot two months. 

In many eases of paraly^ yon wiS find that, altboE^ the pa- 
tiaits have lost the power of ctfteiance, yet the motions of the 
tongue appear to be nowise deranged. In tbe majority of cases it 
can be diortened, eloi^ted, raised, depressed, or moved from side 
to side;, with as much apparent facility as in a state of health ; and 
y^ tbe voice is in some instances very mocb impaired — in others, 
totally lo^ In snch cases it woold appear that the defect lies in 
the giotlis, which forms and modolates the voice, and not in the 
tongue or hps, which divide and articulate it. Indeed, this is evi- 
dent to any one who observes the interrupted and spasmodic 
effi»rts which para!yt»: persons make when speaking ; they are, in 
fact, aE stutterers. 

But to return to tbe case to which I have alluded. A young 

I if it be dmicde or sab-acate, especially if it he 
tabemdaas dqpositiH tke follicles., 
in old ■«■ ti%@nailoiK d^e^tes aoe dv3^ sloir and 
; amd there aie^ Ibaii^iie^TaQr lew ajmptams of ittSamma- 
toiji^etiaB.— £&] 



J 




LOSS OF VOICE. 167 

gentleman of delicate constitution, and who is now about sixteen 
years of age, continued to enjoy tolerably good health up to his 
sixth year. When about six years of age, he went to bed one night 
in health and without any unusual symptom, but on getting up in 
the morning it was observed that he had lost his speech, and was 
unable to articulate a single word. His family became alarmed, 
and sent for a physician immediately ; the boy got some internal 
medicine and a stimulant gargle, and recovered his speech in a few 
days, without the occurrence of any symptom of laryngeal inflam- 
mation or cerebral disease. But what was remarkable in the case 
was this : the boy, who up to this period had spoken well and dis- 
tinctly, now got a terrible stutter. This resisted all kinds of treat- 
ment, and for ten years he continued to stammer in the most 
distressing way, and was so annoyed by it himself that, when a 
boy, he used to stamp on the ground with vexation whenever he 
failed in uttering what he wished to express. In the month of May 
last he got an attack of chronic laryngitis of a scrofulous character, 
and evidently the precursor of phthisis. Indeed, he is at present 
labouring under phthisis; Dr. Stokes and I have examined him, 
and we feel convince^ that tubercular deposition is going on in the 
lungs. But what is most curious in the case is this: after he got 
the laryngitis, a very peculiar change took place; the laryngeal 
inflammation modified the tone of his voice so as to make it a little 
husky, but the stammering has completely ceased. 

You are aware that stammering has been explained as depending 
on spasm of the muscles which are employed in modifying the 
column of air as it rushes through the narrow aperture of the 
glottis. At certain times, and under a variety of circumstances, 
those fine muscular organs become spasmodically affected, the vocal 
chords no longer undergo the same steady and exact tension and 
relaxation, and speech becomes interrupted in consequence of fre- 
quently recurring closure of the glottis. With respect to this dis- 
ease, 1 would beg leave to refer you to a very excellent chapter in 
Dr. Arnott's work on the Elements of Physic, vol. i., p. 644. 

In the case to which I have referred, inflammation taking place 
in the mucous membrane covering these delicate muscular fibres, 
you can conceive that either the thickening of the mucous mem- 
brane, or the alteration in the state of its vitality, may have so 
modified the disposition of the parts, that they become incapable or 
indisposed to undergo those rapid contractions necessary to produce 
stammering, by inducing closure of the glottis at the moment that 
its aperture ought to remain open. The case itself, however, is an 
extremely curious one, and I do not believe that there is any similar 
one on record. Everything which bears on the cure of so import- 
ant a disease as stammering, even though it be accidental, and not 
the result of medical care and ingenuity, is of great value, inas- 
much as it tends to place the causes of the disease in a clearer light. 
In this point of view I look upon the case as one of very great 
interest. 



168 GRAVES'S CLINICAL LECTURES. 

I shall conclude this lecture with a few detached observations on 

hoarseness, or loss of voice, from sore throat or slight laryngeal 
inflammation — a form of disease which is now very prevalent. 

A form of hoarseness is frequently observed in growing boys or 
girls, which assumes a very chronic character, and often resist for 
a long time almost every form of treatment. A boy gets cold, fol- 
lowed by sore throat and feverish symptoms, v/hich may last for a 
few days, and then disappear under the use of aperient medicines, 
or perhaps without any interference on the part of the parents or 
the physician. The feverishness and soreness of throat subside, 
but the hoarseness remains, and the boy can speak only in whispers. 
This condition may last for weeks, and even months, without any 
other symptom whatever; the patient has no cough or difficulty of 
breathing ; his appetite is good, sleep and digestion natural, and 
there is no appearance of emaciation. The only thing amiss with 
him is the impairment of voice, and this continues so long that it 
gives rise to a considerable degree of anxiety on the part of his 
parents. When you examine the fauces, you find no appearance 
of inflammation in the mucous membrane, and there is no super- 
ficial or deep-seated tenderness in the region of the larynx. How- 
are you to treat this form of disease? It depends on a relaxed and 
weakened state of the chordae vocales, and perhaps the muscles of 
the larynx — the result of inflammation of an exceedingly chronic 
character — and will not be benefited by leeches, or antiphlogistics, 
or low diet. The best thing you can do in such a case is to have 
recourse to the use of strong stimulant gargles. You begin with 
a dram of the tincture of capsicum in six ounces of decoction of 
bark, which is to be used five or six times a day. After some time 
you can increase the quantity of tincture of capsicum, but you 
never need go farther than half an ounce in a six ounce mixture. 
In the next place, you will have recourse to frictions over the region 
of the larynx and external fauces with croton oil, which is much 
better adapted for such cases than tartar emetic ointment. The 
eruption produced by tartar emetic ointment is productive of a great 
deal of annoyance, and when the pustules break they prevent the 
boy from w^earing his neckcloth. All the purposes of a counter- 
irritant are quite as well fulfilled by croton oil, and with much less 
inconvenience. The best form of using it is the following : — 

ijc Liniment: camphorae comp. 5j. 
Olei crotonis tiglii, Tr\, xx. 

Of this mixture a small quantity — say a couple of drams — should 
be poured into a saucer, and rubbed over the fore part of the neck 
night and morning, until a full crop of pimples appears. When 
those have dried up and desquamated, it should be again applied, 
and in this way a mild and manageable, but very effectual, degree 
of counter-irritation can be kept up for any length of time. In 
addition to these measures (should the disease continue), I would 



VELPEAU'S TREATMENT OF SORE THROAT. 169 

strongly recommend small doses of iodine, and change of air. I 
have been induced to give iodine in such cases from observing that 
inflammation of a chronic character seems to have many points of 
resemblance to that vi'hich arises from scrofula.* The last thing 
which I have to observe on this form of hoarseness is, that you 
should, particularly in the beginning, insist on the observance of 
strict silence — a point vi^hich is said to be exceedingly hard to be 
attained where the patient happens to be a female. In some cases 
all these means fail, and then something more energetic must be 
attempted. The inhalation of the vapour arising from tincture of 
iodine and tincture of conium, added to hot water in a proper appa- 
ratus, has proved useful to some ; but in all obstinate cases the 
sheet-anchor is mercury exhibited internally, and by means of in- 
haling the fumes of hydrargyrum cum creta. In general, it is 
necessary to continue the mercurials until the mouth is slightly 
touched, w^hen the hoarseness will be found to yield. It is obvious 
that, before we employ mercury in a case of chronic hoarseness, we 
must feel well assured that we have not to deal with a hoarseness 
arising from a phthisical tendency, for in this case mercury would 
prove injurious to the constitution. In such cases the stethoscope 
and percussion often afford valuable assistance, by showing that 
although the patient has had a hoarseness and cough for weeks, or 
even months, yet there are no symptoms of tubercular development 
in the lungs. The cough is only the result of laryngeal inflamma- 
tion or irritation; the submaxillary glands and the amygdalee are 
often slightly enlarged, the fauces are red, and the back of the pha- 
rynx is covered with irregular superficial excoriations. Connected 
with the subject of sore throat is the discovery, lately announced 
by Velpeau, of the use of alum in powder in acute cynanche ton- 
sillaris. He states that this powder, applied by means of the finger 
to the fauces and inflamed parts, exercises a wonderful eflTect. The 
symptoms, says Yelpeau, are stopped as if by enchantment, the 
fever diminishes, the redness and tumefaction of the inflamed parts 
subside, the appetite returns, and convalescence is speedily esta- 
blished. This application is successful at any period^before suppu- 
ration has been estabhshed. Alum has long since been applied in 
substance to the throat, in cases of angina maligna, and in chronic 
sore throat ; but, before Velpeau, no practitioner ever dreamed of 
making use of alum as a local application during the first stages of 
acute cynanche tonsillaris. By the way, this use of alum is calcu- 
lated to throw some light on the good effects which this substance 
exerts, when taken in large doses, in cases of violent pain in the 
stomach arising from indigestion, recommended by Dr. Griffin, of 
Limerick. 

* [The external use of iodine by painting the exterior of the throat with the 
tincture, or rubbing it with iodine ointment, should, in such cases, be added to its 
internal administration. — Ed.'\ 

15 



170 GRAVES'S CLINICAL LECTURES. 



LECTURE XIV. 

There is at present in the hospital, a nnan whose case has been 
marked imperfect or (to use a better phrase) incomplete amaurosis. 
He has been complaining at different times during the past year, 
and for the last six months his vision has been very weak, with the 
exception of occasional intermissions. He can perceive objects 
tolerably well with the right eye, but scarcely at all with the left, 
and in both vision is more or less dim and imperfect. 

On examining this man's eyes, you cannot discover in either of 
them the slightest imperceptible defect as an optical instrument. The 
deficiency of vision, therefore, does not depend on opacity of the 
cornea, on disease of the lens or its capsule, or on any affection of 
the aqueous or vitreous humours; it is simply an impairment of 
the vitality of the organ, connected with functional disease of the 
retina. Having thus satisfied ourselves as to the seat and nature 
of the disease, we come next to inquire into its cause and origin. 
From a careful examination of the man's state of health, we can 
have no doubt on our minds as to whether the amaurosis in this 
case has been produced by derangement of the stomach or not. 
You are all aware that the celebrated Richter has long since 
shown, that functional disease of the retina is often connected with 
a deranged state of the alimentary canal, and that it may be treated 
successfully with emetics and purgatives. Here, however, we 
have no evidence of the existence of congestion or derangement of 
the stomach and bowels. The man's appetite is good, his bowels 
regular, and his health robust. But when we come to examine the 
head, we find evidence of cerebral congestion sufficient to account 
for the functional lesion of the optic nerve. Our patient has been 
a long time complaining, at different periods, of a sense of fulness 
^n the head, and is subject to attacks of vertigo while walking, 
causing him to stumble occasionally, and labour under frequent 
apprehensions of falling down in the street. He prefers walking 
along the middle of the street to either side, and says that he is 
always worse when he attempts to walk along the flagway. This 
is an ordinary symptom observed among persons who have a ten- 
dency to vertigo ; they are frequently made worse by the operation 
of causes in themselves apparently inconsequential, and the nature 
of which we cannot well understand. You are aware that, in 
many persons, the act of looking for any length of time at objects 
moving rapidly in a straight line, and still more in a circle, has a 
tendency to produce giddiness. Thus, looking out of the window 
of a steam-carriage on the objects apparently moving backwards 
with great velocity, or looking over a bridge at the current of a 
rapid river, or gazing at a person whirled round in a gyrating 
swing, is very apt to give rise to vertigo. Again, persons labour- 
ing under a morbid sensibility of the brain, very often become 



AMAUROSIS, 171 

giddy from looking at a succession of objects moving with much 
less rapidity. Hence you will find such persons made giddy by 
walking through a crowded city, and having a number of persons 
pass by them on the flagway, and they seek for an opportunity of 
getting into the middle of the street, to avoid meeting so many 
objects. I knew a person who could never pass by a line of railing 
with any degree of comfort ; if he happened to look at them as he 
moved by, he became almost immediately vertiginous. Giddiness 
is also generally produced by looking down from a great height, in 
a vertical direction, or by looking upwards, provided the object be 
immediately overhead, and at a great distance. Under these cir- 
cumstances, most persons experience a feeling of vertigo, no matter 
what their position may be at the time. There seems to be little 
doubt that the sensation of giddiness does not depend merely on 
the distance or position of the object looked at. It would appear 
that, in general, some continuous communication must exist be- 
tween that object and the spectator. Thus we feel giddy when we 
look down from a precipice at something below, or when standing 
beneath the dome of St. Peter's or St. Paul's we regard with atten- 
tion the vaulted structure above ; but we do not feel giddy when 
we look down from a balloon, or look upwards at the moon or stars 
near the zenith. It has not been sufficiently remarked by writers, 
that persons subject to vertigo are often almost as much affected by 
looking upwards as by looking downwards. Persons w^ho are in- 
clined to vertigo, will also become giddy by directing the eye with 
a fixed attention for any length of time to the one object, — such as 
continuing to look in a straight line, or endeavouring to direct the 
course of their movements along a plank or narrow pathway. 
These circumstances are all very difficult to explain, and I bring 
them forward merely as illustrating the fact of this man's prefer- 
ence for walking in the middle of the street. 

In this man, as you may have perceived, we had several circum- 
stances calculated to direct our attention to the state of the brain as 
connected with the impairment of vision ; besides vertigo, and a 
tendency to stumble in walking, he had flashes of light before his 
eyes, and other luminous hallucinations, with tinnitus aurium on 
one side. With respect to the flashes of light before the eyes, I 
may observe, that they may be produced by the operation of 
various causes ; a blow or pressure on the eye will cause them ; 
they may arise also from a particular state of the arteries which 
supply the optic nerve, and thus at each pulsation of the heart a 
flash of light is seen. This morbid sensibility of the retina, which, 
under such circumstances, appears to be itself the source of light, 
is very often a symptom which ushers in the extinction of the 
visual power. It is a very general remark, that hypersensibility of 
an organ is but too often the prelude to total loss of its functions. 
Thus we frequently have a morbidly sensitive state of the eye be- 
fore it becomes incurably amaurotic, a morbid sensibility of the ear 
ushering in loss of hearing, and unnatural excitement of the sense 



172 GRAVES'S CLINICAL LECTURES. 

of touch preceding paralysis. But in this case we have not only 
an irritable condition of the retina, but also an affection of the 
pupil ; the iris is sluggish in its motions, and this symptom occur- 
ring at this particular period, combined with the vertigo, luminous 
hallucinations, and gradual but steady progress of the disease, give 
us some reasons to apprehend that it will end in complete amaurosis. 
Seeing, however, that the symptoms have originated in a congested 
state of the brain, it is our duty, as far as possible, to check its pro- 
gress. This is to be done by cupping over the nape of the neck, 
leeching the temples and behind the ears, and acting on the bowels 
by brisk purgatives. With the same view, I intend to insert a seton 
in the nape of his neck, and to administer the nitrate of silver in- 
ternally, combined with a small quantity of aloes, a remedy which 
is possessed of some valuable properties in the treatment of chronic 
congestion of the brain, whether tending to produce amaurosis or 
headache. 

With respect to the causes of amaurosis, I may observe, that 
they depend either on disease of the brain, as congestion, inflamma- 
tion, the presence of tumours of various kinds, or on injuries of the 
retina itself, or of the supra and infra-orbital branches of the fifth 
nerve, or on affections of the alimentary canal. All these matters, 
however, have been so well detailed, particularly in the excellent 
article on amaurosis, by Dr. Jacob, in the Cyclopaedia of Practical 
Medicine, to which I refer you, that I shall pass over them at pre- 
sent, and close my notice of this case with a few desultory remarks. 
I believe I mentioned in a former lecture, that I had seen a very 
curious case of amaurosis, in which the cause of the disease seemed 
to be connected with an impression made by cold on the facial 
branches on the fifth nerve. I have already taught the class, that 
paralysis of any part of the body may arise from an impression 
made not only on its own nerves, but also on the peripheral ex- 
tremities of the nerves of another and even a distant part. I have 
also remarked that the fifth nerve is connected with the nerves of 
all the senses, but in particular with the optic, and hence we can 
explain why injuries of its supra and infra-orbital branches may 
bring on amaurosis. In the case to which I refer, the patient was 
exposed, while travelling outside on a stage-coach, to a keen north- 
easterly wind, and when he arrived in Dublin, his lips were very 
much chapped, and the skin of his face bore evident marks of the 
cold, and drying powers of the wind. Soon afterwards, he began 
to complain of dimness of vision, and a thin gauze veil seemed to 
be extended between him and every object he looked at. After 
five or six days when he applied to me, I found a considerable 
degree of amaurosis present, and at the distance of a few feet he 
was unable to recognise the countenance of a friend. He had no 
headache, vertigo, or tinnitus aurium ; in fact, nothing to indicate 
cerebral congestion, and his appetite was good, sleep undisturbed, 
bowels regular. He had never thought himself, nor did a medical 
gentleman, to whom he had applied, ever suspect, that the impres- 



i 



AMAUROSIS. 173 

sion of cold on the face had produced the amaurosis, and he said 
that he had been advised to get himself leeched and cupped over 
the back of the neck. On examining into the cause of his disease, 
and having found that he had been exposed to severe cold, it 
occurred to me that the amaurosis might be connected with the 
impression made by cold on the superficial branches of the fifth 
nerve, and, on more accurate investigation, I found that there were 
some grounds for this opinion. I was further confirmed in this 
view of the subject by the details of a case communicated to me by 
my friend, Dr. Montgomery, in which the patient evidently got 
paralysis of the portio dura from exposure of one side of the face 
to cold. Of course this paralysis was attended with distortion of 
countenance, in consequence of many of the muscles of the face 
depending on the portio dura for their supply of nervous energy. 
But what was particularly remarkable in this case, was, that vision 
on the affected side of the face became dim and indistinct. Now, 
can this be explained ? Yes, very easily. You all know that the 
branches of the portio dura have an extensive communication with 
the supra and infra-orbital branches of the fifth. Now, the para- 
lysis which commenced in the portio dura, gradually extended to 
the branches of the fifth, and through them to the optic nerve, 
with which the fifth is intimately connected, and hence it was the 
retina became finally deranged in its function, and dimness was 
produced. 

There is one circumstance more to which, as I am on the subject 
of amaurosis, I shall briefly call your attention. You will recollect 
the case of a boy whom we have had very recently under treatment 
for amaurosis, and may perhaps remember that one of the remark- 
able points in his case was this : — when he looked straightforward 
he did not see anything in the direction to which his eyes were 
turned, but he could see the objects that were considerably below, 
or to either side of, the axis of vision. There are two or three cir- 
cumstances under which a person cannot see an object by looking 
directly at it, and I wish to state these circumstances. In the first 
place, it may happen that an opaque spot may be situated on the 
centre of the cornea and directly in the axis of vision, as we some- 
times see in cases of scrofulous ulceration, followed by permanent 
opacity of the cornea. Now, in this case, it is plain that the person 
cannot see objects placed directly before him and in the axis of 
vision. The second case is one where the patient cannot see ob- 
jects directly before him, but can distinguish them tolerably well at 
a certain angle of obliquity, the cornea being perfectly clear and 
uninjured in its texture. Now, this may arise from an opacity of 
the lens, limited to its centre, and not generally diffused through 
its substance. The lens is a compound body, the structure of which 
was, until very lately, but little known. When the lens or its cap- 
sule is aflfected with opacity, this opacity is not always equally 
diffused, but sometimes occupies the central portions of these 

15* 



174 GRAVES'S CLINICAL LECTURES. 

organs, while the circumferential portions retain their transparency. 

Hence, when a person under such circumstances wishes to see an 
object, it is necessary that the rays of light should fall obliquely in 
order to reach the retina. A third case is, where, although the 
cornea and crystalline lens are in the natural state, still the patient 
sees objects a little removed from the axis of vision much better 
than those which are in it, as in the case to which I have just 
alluded, where the patient could scarcely distinguish any object 
placed directly before him, but see tolerably well objects at either 
side of, or below, the direct line. The reason of this appears to be, 
that when a person so circumstanced looks directly at an object, 
the picture of the object falls on a part of the retina not obedient to 
the stimulus of light. In the process of ordinary vision the parts 
around the axis, and corresponding to the field of vision, have the 
picture of the object looked at painted on them, and vividly and 
strongly illuminated. The central portion of the retina bears on it 
the picture of the object which the mind attends to, for it is sur- 
prising how indistinct and how little attended to any object seen 
obliquely is. Now, where disease has rendered this central portion 
of the retina insensible to light, then the attention is immediately 
turned, with a greater degree of intensity, to the sensations 
derived from the surrounding portions, and the patient is enabled, 
so long as this portion retains its sensibility, to enjoy the sight of 
objects placed obliquely and not in the axis of vision. Even in 
healthy eyes the non-central portions of the retina may be rendered 
available in particular cases. This has been proved by Brewster, 
Herschel, and others. In looking, for instance, at a star of the 
smallest magnitude, it vanishes from the sight and is lost when 
looked at directl}^ but, if 3-ou turn a Httle from it, it will still catch 
the eye and be visible, because the image of the star will now fall 
on a part of the retina which is generally in darkness, and which 
is more sensible from being unaccustomed to the glare of light. 
Hence in many cases of amaurosis it is not unusual to find that the 
patient retains the power of vision so far as regards objects placed 
at an oblique angle with the axis of the eye after direct vision has 
been all but extinguished. This is all I have to say at present 
with respect to amaurosis. 

As there is no other case presenting peculiarities to which I 
might call your attention, I shall beg leave to occupy your time for 
the remaining part of our lecture hour with a detail of the circum- 
stances under which I have been led to employ the acetate of lead 
in Asiatic cholera, and to communicate briefly the mode of its ad- 
ministration and the results which attended its use. You are aware 
that during this epidemic, which commenced its fearful career in 
DubUn in the spring of 1832, the modes of treatment principally 
relied on were, bleeding in violent spasmodic cases, emetics of ipe- 
cacuanha and mustard, the application of heat externally, and 
internally stimulants, but, above all, calomel, not in small but in 
large and frequently repeated doses, either alone or combined with 



ACETATE OF LEAD IN CHOLERA. 175 

opium. I need not tell you that the mercurial treatment came to 
us sanctioned by high authority: it was a remedy to which the 
experience of Indian practitioners had given a high character, but 
in our hands, I must say, it proved of very little value. Be this as 
it may, I must say that I had reason to be dissatisfied with this 
mode of treatment ; I had tried it myself, and had seen it tried in 
every way which ingenuity or experience could suggest, but 1 had 
seen it fail in almost every instance. 

About the middle of last summer the epidemic began to spread 
fearfull}^ among those who had hitherto been exempt from its at- 
tacks ; many persons in respectable life were seized, and my private 
practice afforded numerous opportunities of becoming practically 
acquainted with the disease. In several cases to which I was called 
in, the malady had not advanced to the stage of collapse, the symp- 
toms of cholera, properly so called, had merely commenced, the 
intensity of the disease was still far away, and a fair chance was 
afforded for the operation of therapeutic agents. In most instances 
1 tried calomel and all the ordinary remedies with profitless results^; 
my treatment proved too often ineffectual ; and some persons, whose 
lives I highly valued, perished in spite of all my efforts, leaving me 
grieved for their loss, and mortified by my own want of success. I 
found that I could no longer place any confidence in calomel, and 
determined, in my own mind, to give up a remedy which had so 
signally failed ; it was, however, a question of deep anxiety to me 
what I should select instead, or to what article in the Materia 
Medica I should have recourse, where so many had proved utterly 
valueless. 

About this period I happened to be called on to attend a case of 
obstinate diarrhoea with my friend Dr. Hunt. The case was an 
extremely harassing one, and had resisted all the ordinary reme- 
dies. 1 advised the use of acetate of lead and opium in full doses ; 
this was given, and I had the satisfaction of finding that the diar- 
rhoea soon yielded. Before this period I had received a letter from 
that able practitioner and excellent man, Dr. Bardsley, of Man- 
chester, directing my attention to the use of acetate of lead in large 
doses in that form of diarrhoea which occurs towards the termina- 
tion of long fevers, that is to say, the diarrhoea which precedes and 
accompanies inflammation of the glands of the small intestines. I 
had subsequently, at Sir P. Dun's Hospital, several opportunities of 
witnessing the truth of Dr. Bardsley's remarks. I saw that, in many 
cases during the course of fever, where the patient was low and 
prostrated, symptoms of intestinal congestion came on, followed by 
diarrhoea, which many persons thought would end in ulceration of 
the glands of Peyer ; and I found that in such cases the acetate of 
lead was the only remedy that could be relied on. I observed, too, 
that, contrary to the prevailing opinion on the subject, it could be 
given in large doses with perfect safety. You are aware that Dr. 
Bardsley has shown that it may be given to children in very con- 
siderable doses without any bad effects; and that in adults he has 



176 GRAVES'S CLINICAL LECTURES. 

pushed this remedy to the extent of twenty or thirty grains in the 
day, without any unfavourable consequences.* 

With these impressions I came to the resolution of trying the 
acetate of lead in the next case of cholera which offered a chance 
of deriving benefit from any kind of treatment. It is known that 
there are some cases in which the disease at once assumes so fright- 
ful a malignity, that the patient is lost from the very moment of his 
seizure. This hopeless and intractable malignity is not peculiar to 
cholera; it is seen in fever, scarlatina, croup, measles, and hydro- 
cephalus ; in fact, there are certain forms of all diseases in which 
the best directed efforts of medical skill not only fail in curing the 
disease, but even in retarding its progress. But there are cases of 
cholera where the patient is not struck down at once, where the 
disease is not developed at once in all its awful intensity, and where 
time, brief though the space may be, is allowed for the play of 
therapeutic agencies. It is in such cases the acetate of lead may 
be given with some prospect of success, and it is by such cases 
alone, and not by those which are necessarily fatal ab initio^ that 
its value is to be tested. 

Before we proceed further, I may observe, that the principle on 
which the calomel treatment was employed in cholera arose from 
almost constantly observing that there was a total deficiency of bile 
in the stools. Soon after the supervention of an attack, the alvine 
discharges were observed to be white and without the slightest 
tinge of bile; and on this very remarkable symptom practitioners 
dwell almost exclusively, thinking that the patient's only chance 
lay in restoring the secretion of the liver. Now it is obvious that 
the absence of bile in the stools is no more a cause of the disease 
than is the deficiency of urea in the kidneys or of serum in the 
blood. Viewing the disease in this light, it would be just as reason- 
able to give a diuretic to restore the secretion of the kidneys, as 
to give calomel to produce a flow of bile. The fiver ceases to 
secrete, not only in consequence of the injury done to its vitality by 
the proximate cause of cholera, whatever that may be, but also 
from a mechanical cause, namely, from a diminution in its supply 
of blood. It may appear strange that when the same given number 
of vessels go to the liver and come from it at all times, that the 
quantity of blood circulating in it should be greater at one time 
than another. I have not time at present to enter fully into this 
subject ; but it is a fact admitting of suflScient proof, that the quan- 
tity of blood circulating in any organ is very much modified by the 
state of its capillaries. The quantity of blood also which goes to a 
gland varies according to the peculiar state of that gland, being 
greater during its period of active secretion than when it is at rest. 
But in a case of cholera, where the capillary vessels of the intesti- 
nal canal from the stomach and the rectum are actively engaged 

* [Iq a case of severe dysentery with large heraorrhag-e from the bowels, Dr. 
Horner of this city and myself gave it in doses of two grains every hour; that is, 
forty-eight grains in twenty-ibur hours, without the slightest bad effects, — Ed.\ 



ACETATE OF LEAD IN CHOLERA. 177 

in taking up the serum from the whole mass of blood, and pouring 
it into the cavity of the digestive tube, there is an enormous drain- 
age, from the system, and there must be, consequently, a deficiency 
of blood somewhere. Now it would appear that a quantity of 
blood, sufficient for the purposes of secretion, is abstracted, not only 
from the biliary, but also from the urinary system ; and hence it 
appears just as reasonable to give diuretics to restore the urinary 
secretion, as to give calomel to excite the secretion of the liver. It 
would be, d, 'priori^ as original a mode of treatment, and be equally 
as successful. I have, therefore, no hesitation in saying, that the 
calomel treatment has no claim to merit on the ground of theory, 
and, as far as I have observed of it in this country, it seems to be of 
no practical value in the treatment of cholera. 

With regard to the quantity of acetate of lead which may be 
given in this disease, and the mode of administering it, a few words 
are necessary. I have already stated that, when I first tried it, I 
prescribed it in large doses, fortified by the authority of Dr. Bards- 
ley, and by my own experience, of its utility in many cases of 
diarrhosa. It appears that, before I recommended the acetate of 
lead, it had been used at the Cholera Hospital in Grangegorman 
lane. Of this I was not aware, until a book was subsequently 
published by Dr. Cranfield, which I afterwards reviewed in the 
Dublin Medical and Chemical Journal, and I feel that on that oc- 
casion I did fair and impartial justice to its merits. I certainly did 
not know that the acetate of lead had been given at the Grange- 
gorman Hospital ; for, in the very able report of cholera, as ob- 
served at that institution, published by one of its officers, Mr. M'Coy, 
the treatment relied upon appears to have been the mercurial, and 
not a word was said of acetate of lead. It had certainly been used 
there by one physician ; but it was given in smaller doses, insuffi- 
cient to produce decided effects, and no stress had been laid on its 
value as a remedy in cholera by the practitioners attached to the 
hospital. Be this as it may, acetate of lead was not known to the 
medical men of Dublin, and to the practising apothecaries, before I 
recommended it. It had been frequently employed in the form of 
injection by them, but no one had given it in large doses by the 
mouth, or introduced it to the particular notice of the profession. 
I believe I can fairly claim the merit, such as it is, of being the first 
to give it in large and effectual doses. The mode in which I pre- 
scribed, was this : — A scruple of the acetate of lead, combined with 
a grain of opium, was divided into twelve pills, and of these one was 
given every half hour, until the rice water discharges from the 
stomach and rectum began to diminish. In all cases where medi- 
cine promised any chance of relief, this remedy was attended with 
the very best eflfects. It gradually checked the serous discharges 
from the bowels, and stopped the vomiting. I need not say of what 
importance this is ; as long as these exhausting discharges continue, 
as long as the serum of the entire body continues to be drained off 
by the intestinal exhalants, what hope can we entertain ? What 



178 GRAVES'S CLINICAL LECTURES. 

benefit can be expected from calomel and stimulants, when every 
function of the digestive mucous membrane seems to be totally 
extinguished, except that of exhalation, and while profuse dis- 
charges, occurring every five or ten minutes, are reducing the 
patient to a stale of alarming prostration? Knowing the inevitable 
fatality of all cases where these discharges went on unchecked, I 
was happyin having discovered a remedy which seemed to possess 
more power in arresting them than any yet devised, and this im- 
pression was confirmed by the results of subsequent experience. 
That the acetate of lead will succeed where all other astringents 
fail, was proved by the case of Mr. Parr, of this hospital. Having 
got an attack of threatening diarrhoea, at a time when cholera was 
prevailing in Dublin, this gentleman used various kinds of astrin- 
gents, and took so large a quantity of opiates that he became quite 
narcotised, but without any relief to his symptoms. When I saw 
him he was as bad as ever, and was beginning to exhibit appear- 
ances of collapse. I advised the use of pills, composed of acetate 
of lead and opium, in the proportions already mentioned, and had 
the satisfaction of finding that before night the diarrhosa had ceased. 
The pills are to be used one every half hour while the diarrhoea 
remains unchecked, but as it begins to diminish, the intervals be- 
tween each pill may be prolonged, and in this way the patient may 
be gradually prepared for leaving off the remedy altogether. I 
have frequently given in this way as much as forty grains of 
acetate of lead in twenty-four hours, with great advantage to the 
patient, and without any bad consequences ensuing.* 

It is unnecessary for me to say any more on this subject ; if I 
chose to mention names, I could bring forward the names of many 
medical men in Dublin whose lives, I am happy to state, were 
saved by the use of this remedy. I may, however, observe, that 
this mode of treatment has now become universal here, and that it 
has almost completely superseded the use of calomel and opium. I 
will confess that this fact is a source of high gratification to me, 
and I point also with pleasure to the fact, that since it became ex- 
tensively known (as it did during the last invasion of the epidemic), 
the profession has gained more credit than before, and the number 
of cures has been proportionally greater. 

I have referred to this subject also for another reason. I feel it 
a duty which I owe myself, to defend myself against a series of 
attacks which were made on me, and to vindicate my claims, not 
to having been the first to administer acetate of lead, for it had 
been given previously by Dupuytren, and at the Grangegorman 
Cholera Hospital, but to having been the first to prescribe it in 
large and sufficient doses, to render it an available and useful 
remedy, and to introduce it to the general notice of the profession. 
The credit to which I lay claim, rests solely on these grounds. I 

* [It has long been the practice with American physicians to give the acetate 
of lead in larg;e doses. -^ Ed.] 



MOBILITY OF THE STERNUM. 179 

have been attacked on more than one occasion in the public papers, 
and gentlemen subscribing themselves Honestas, Candidus, and 
Verax, ('per antiphrasitii I suppose, for they have shown neither 
honesty, candour, nor truth,) have attempted to rob me of the merit 
of what they sneeringly called the lead treatment. I am not in the 
habit of noticing attacks in the daily or weekly papers, but I have 
thought it necessary to say so much in the way of explanation, 
lest any of my friends or pupils should misinterpret my silence. 

The following case of remarkable mobility of the sternum was 
observed by Dr. Stokes and myself A medical student, nineteen 
years of age, and of a sanguineous temperament, who had often 
been attacked by violent pectoral inflammation, particularly a few 
years ago, but who had since become comparatively healthy and 
robust, applied to me for advice concerning a pain in his chest. 
This happened after lecture in Sir P. Dun's hospital, in the pre- 
sence of several of the students and Dr. Law, who saw with asto- 
nishment this young man open his shirt, and with his hand push 
the sternum deep inwards towards the spine, so as to convert the 
anterior part of the chest into an extensive and by no means 
shallow cavity, at the bottom of which was the sternum. The ra- 
pidity with which this was effected, and the unnatural appearance the 
chest then presented, excited a most disagreeable feeling of alarm 
in the minds of the spectators, for we could not avoid dreading that 
he was inflicting on himself some serious injury. 

The portion of the chest which yielded in this singular manner 
to pressure, comprised the sternum from within two inches of its 
superior edge, and seemed below this point to be limited laterally 
by the lines answering to the junctions of the cartilaginous with 
the osseous portions of the ribs, so that the whole space capable of 
being pressed inwards was nearly triangular in shape, and was 
very extensive. The sternum was so tender to the touch, that, in 
applying the pressure, he was obliged to press at some distance at 
each side of this bone. When the pressure was carried to the 
farthest point, the sternum was pushed in, as nearly as we could 
guess, about two inches, and the action of the heart, as well as that 
of the subjacent lung, appeared to be notably diminished, and, in 
consequence of this the pulse was weakened. This young man 
was subject not only to constant pain in the sternum, but likewise 
to frequently recurring violent palpitations of the heart. His chest 
was sufficiently ample and well formed, but he had lately become 
round shouldered, in consequence of his seeking relief from pain 
by stooping forward. No other portion of his osseous system ex- 
hibited the least trace of softening. The only aflfection which I 
can call to mind the least resembling this, is the softening which 
sometimes affects the female pelvis, giving rise to great distortion, 
and which softening is accompanied, during the months or even 
.years of its formation, by severe pelvic pains. 



ISO GRAVES'S CLINICAL LECTURES. 



LECTURE XV. 

Case of phlebitis — Remarks on the symptoms and treatment of this disease — Patho= 
logy of phlegmasia dolens — Its treatment — Case of cancrum oris — Fatal termina- 
tion — Remedies employed — Case of ague cake — Observations on the different 
varieties of ague — True ague, or intermittent fever — Ague produced by inflam- 
mation of internal organs — Nervous ague — Hysterical ague — Treatment of ague 
cake. 

Among the cases at present under treatment in our wards, that 
of Mary M'Quade particularly demands your attention. This poor 
woman was admitted a few days since labouring under an attack 
of fever, accompanied by considerable prostration, anxiety, and rest- 
lessness ; in addition to these symptoms, she has a local affection 
of a very important nature ; the right leg, as far as the knee, is 
swelled to twice its natural size, and a large erysipelatous blotch 
occupies the fore part of the foot, extending over the ankles on each 
side. The thigh also is increased in size as far as its upper third, 
so that the tumefaction embraces more than two-thirds of the w-hole 
extremity. There is a considerable degree of tension present, 
and the limb, particularly along the internal surface of the leg, is 
extremely tender, the soreness being so great over the course 
of the veins and lymphatics, that she could not bear the shghtest 
touch. 

Here we had a swelling of the lower extremity depending on an 
inflammatory condition of the part, and the question is, in what 
tissue did it commence, and what are its characteristic features? 
Before w^e discuss this question, it may be proper to observe here 
that the disease had its origin from cold. When a patient is ex- 
posed to cold under unfavourable circumstances, local inflammation 
is generally the consequence, and it depends on a variety of causes 
of what description the inflammation will be, and on what parti- 
cular part it will fall. Where the lower extremities are the parts 
chiefly exposed, inflammation of the cellular membrane of the leg 
is apt to ensue, or it may attack the veins, as in the case before us, 
constituting phlebitis, or the lymphatics may be primarily and al- 
most exclusively engaged. In a few cases inflammation attacks 
the arteries of the limb, as in a case which has been published by 
Dr. Stokes and myself in the Dublin Hospital Reports, where a per- 
son, after exposure of the lower extremities to cold, got an attack of 
arteritis, terminating in mortification of the limb and death. Expo- 
sure of the lower extremities to cold gives rise to phlebitis much 
oftener than to arteritis. Dr. Stokes and I have published a striking 
case where inflammation of the veins of the leg was produced by 
this cause. You will find this case referred to by Dr. Lee, in the 
excellent article. Phlegmasia Dolens, in the Cyclopaedia of Prac- 
tical Medicine. You perceive, then, that painful swelling of the 
lower extremities originating in cold, may consist either in the 
whole cellular membrane being engaged, or it may arise from in- 



PHLEGMASIA DOLENS. 181 

flammation of the lymphatics of the veins, or of the arteries. Now 
when inflammation attacks in the first instance the subcutaneous 
tissue of the lower extremities, it frequently in its progress involves 
the lymphatic and venous tissues, the arterial very seldom, for the 
arteries lie deep, and have no connection with the subcutaneous 
cellular membrane. There is, however, nothing more common 
than that inflammation commencing in this way should terminate 
in phlebitis, and disease of the lymphatics. This appears to be 
the nature of phlegmasia dolens, that peculiar inflammation which 
generally attacks one, and seldom both, of the lower extremities, 
which is most commonly observed in females, and which is cha- 
racterised by swelling not pitting on pressure, by excessive cuta- 
neous tenderness, and by a remarkable whiteness of the skin of the 
aflected limb, accompanied by increased heat, and more or less 
lesion of the locomotive function. These are the principal symp- 
toms which characterise phlegmasia dolens. The inflammatory 
condition of the limb causes an exudation of fluid into the cellular 
membrane, consisting partly of serum and partly of lymph; this 
produces swelling which is of a firm and rather unyielding cha- 
racter, not pitting on pressure like that which results from anasarca. 
After some time the inflammation extends to the neighbouring tis- 
sues, and attacks the veins and lymphatics, a circumstance which 
has led many persons, among others Dr. Lee, to believe that phleg- 
masia dolens arises primarily from phlebitis. This, however, is 
not borne out by the fact, nor is it true that it consists in inflamma- 
tion of the lymphatics, as others have suggested; it may engage both 
the lymphatic and venous tissues, but it differs in many points from 
pure phlebitis, or true inflammation of the lymphatics. 

In the case before us, it would appear that the inflammation 
commenced primarily in the veins, and by a careful examination 
you will be able to discover some essential points of difference be- 
tween the disease and phlegmasia dolens. There is a good deal 
of soreness present in this case, but the exquisite neuralgic tender- 
ness of phlegmasia dolens is wanting. Again, the shining appear- 
ance of phlegmasia dolens is absent, and the colour difl^ers greatly 
from the dead whiteness observed in that disease. The tenderness 
also is here more localised, being chiefly complained of on the 
inside of the limb, and along the course of the veins and lympha- 
tics. On the other hand, it may be observed that these affections 
have many symptoms in common, and you may have remarked 
that here, as in phlegmasia dolens, the locomotive power of the 
limb is considerably diminished. This, however, has been reme- 
died, to a certain extent, by the curative means employed, and the 
patient is now able to raise up the whole limb, and bend the leg on 
the thigh. Now, whence arises this loss of power so often wit- 
nessed in cases of phlegmasia dolens, and phlebitis, and inflamma- 
tion of the subcutaneous cellular tissue of the lower extremities'? 
I am inclined to think it depends on a morbid impression made on 
the ultimate ramifications of the sentient nerves, which is propa- 

10 



1S2 GRAVES'S CLIJSICAL LECTURES. 

gated along the larger trunk to the spinal cord, and from thence by 
a reflex course is brought to bear and react on the muscular nerves 
of the limb. In my remarks on paraplegia, I have spoken of this 
matter at large, and given several instances of loss of power in a 
limb, produced by impressions made on the extremities of its cuta- 
neous nerves ; and such appears to be the lesion of the locomotive 
power observed so frequently in cases of phlebitis and phlegmasia 
dolens. In many cases of paralysis, we find the first stage of the 
disease attended with an increased sensibility of the nerves of the 
part affected, tending to show that the primary source of the disease 
consists in an impression made on the sentient extremities of the 
nerves; and there is nothing more common in such cases than to 
find the loss of the motor power accompanied by deranged sensa- 
tion. In phlegmasia dolens and phlebitis we have great cutaneous 
tenderness, and this is very rapidly followed by more or less dimi- 
nution of the muscular power of the limb. 

I shall now refer briefly to the curative means employed in this 
case, observing that it has this in common with many cases of 
phlegmasia dolens, viz., the inflammation has engaged in succession 
the cellular membrane, veins, and lymphatics. When the lym- 
phatics are attacked with inflammation, they become swelled, and 
have a knotty cord-like feel, and this condition is most commonly 
attended with the appearance of erysipelatous patches on various 
parts of the limb, over the place where a number of lymphatics are 
simultaneously engaged. This appears to be the case in the present 
instance, and it explains the occurrence, of the erysipelatous blush 
which covers the instep and ankle. I need not tell you that the 
appearance of erysipelas over any part of a limb so circumstanced, 
strongly demands our attention, as it might be an indication of the 
seat of an injury which may have given rise to the disease. In this 
case, however, it was the product of the disease, and had no con- 
nection with its origin. The treatment of a case of this description 
cannot be conducted on strict antiphlogistic principles. The fever 
which accompanies venous inflammation is of a low typhoidal cha- 
racter, and prostration sets in at a very early period. The intimate 
connection of the venous system with the whole economy, the pe- 
culiar character of the inflammation affecting venous tissue, and 
the rapid prostration of strength which ensues, arc all circumstances 
which contra-indicate general depletion. On the other hand, the 
best effects have been obtained by active local bleeding, and this 
appears to be so much the more necessary in cases of phlebitis, as 
the inflammation is apt to run very quickly into the suppurative 
.stage. I therefore ordered forty leeches to be applied along the 
inside of the affected limb, directing the nurse to encourage the 
bleeding by warm fomentations. In addition to this, two ounces 
of mercurial ointment, combined with two drams of the extract of 
belladonna, were spread on large pieces of lint, and applied over 
the limb after the leech-bites had ceased to bleed. That mercurial 
ointment thus applied has a tendency to subdue inflammation of a 



PHLEGMASIA DOLENS. * 183 

low erysipelatory character, has been shown by Mr. M'Dowel in 
an excellent paper published in a late number of the Dublin Medical 
and Chemical Journal. To this we added the extract of belladonna, 
because the local inflammation was attended with hypersensibility 
of the limb, a condition over which belladonna is known to possess 
a remarkable influence. Dr. Lee, I should observe, does not appear 
aware of the great utility of narcotics in the painful swelHng of the 
extremities after fever, or in true phlegmasia dolens. In both these 
diseases, together with active local depletion by means of the fre- 
quent application of leeches, we should employ anodyne ointments, 
and, above all, large doses of opium internally. Some patients in 
phlegmasia dolens, if the bowels be regulated, will bear and derive 
benefit from four, five, or even six grains of opium in the day; I 
speak of the second stage of the disease. The same observation 
applies with regard to wine, and to sulphate of quinine. It is obvious 
that phlegmasia dolens consists of something besides mere inflam- 
mation ; the pain is altogether different from that attending ordinary 
phlegmasia; it more resembles a general neuralgia of the extre- 
mities of the subcutaneous nerves. The internal treatment consisted 
in giving a few grains of hydrarg. cum creta three times a day, to 
keep up a free state of the bowels, and with the view of gently 
affecting the system. These means are very likely to be attended 
with success. The woman at present is much better, and the in- 
flammation is sensibly declining. I shall not, however, anticipate 
the result, and for the present shall only call your attention to the 
case. 

You may perhaps ask me to account for the great tumefaction 
of the limb observed in this case. It has been supposed by some 
persons that the whole swelling depends on the obstruction of the 
veins; but if inflammation was entirely limited to the veins, the 
swelling could not be so extensive. It is true that if you produce 
artificial obstruction of any of the great veins, by placing a ligature 
on it, you cause, for the time, very considerable oedema of the 
limb. The obstruction to the passage of blood through an inflarned 
vein will necessarily give rise to a certain degree of swelling, but I 
am inclined to think that this is not the only source of the tumefac- 
tion ; it would appear that in addition to phlebitis we have the 
inflammatory process communicated to the neighbouring parts ; the 
cellular tissue and probably the lymphatics become engaged, there 
is a copious eflfusion of serum and lymph, and to this the general 
increase in size of the limb is to be chiefly attributed. 

With respect to the termination of phlebitis, I may remark that 
it generally ends in adhesion of the sides of the vein and oblitera- 
tion of its cavity, so that when the patient recovers, the aflfected 
vein feels like a piece of whipcord lying under the skin. We had 
some patients here who had obliteration of this kind, and in one of 
them who died afterwards of fever, I found some of the smaller 
subcutaneous veins had become totally impervious through their 
whole extent, and resembled hard cords. This is all I have at pre- 



184 GRAVES'S CLINICAL LECTURES. 

sent to say with respect to phlebitis, observing that the diseases 
which are most analogous to it are phlegmasia dolens, and a par- 
ticular morbid enlargement of the lower extremity, which has been 
described by Dr. Tweedie, and by Dr. Stokes and myself in the 
Meath Hospital Reports. 

A child about four or five years old, who has been for some time 
in the fever ward, has been recently attacked with a very formi- 
dable disease, cancrum oris. Like most patients labouring under 
this malady, she had been previously debilitated by the occurrence 
of fever, for a child in good health seldom, indeed, I may say never, 
gets an attack of this kind. A preceding febrile condition of the 
system, and a depraved habit of body, must have existed in every 
case where cancrum oris occurs. The disease itself is nothing 
more than mere local inflammation setting in under unfavourable 
circumstances, and during a morbid state of the system, and hence 
the local inflammation rapidly assumes the gangrenous character. 
In children, many forms of general disease* are apt to bring on a 
state of the system in which inflammation of any part has a strong 
tendency to run into gangrene, and this is to be borne in mind 
with reference to the present case, for cancrum oris has nothing 
peculiar in it except its situation. 

It is not my intention at present to enter into any particular de- 
cription of this disease, it has been well described by many surgical 
writers, and you will find a very valuable essay on the subject 
published by Dr. Cuming in the fifth volume of the Dublin Hospital 
Reports. There is also a very excellent article on cancrum oris 
in the London Cyclopaedia of Practical Medicine, to which I beg 
leave to refer you. It may, however, be necessary to allude briefly 
to some points connected with its treatment. In the first place, I 
may observe, with reference to the general principles of treatment, 
that you should not be misled by the name of the disease, or think 
that because there is a gangrenous condition present, you should 
rely exclusively on detergent and antiseptic remedies. This is a 
common but pernicious error — it is the error of prescribing for 
names and not diseases, the easy but dangerous practice of unre- 
flecting empiricism, by which the reputation of medicine has been 
so often damaged. He who commences the treatment of cancrum 
oris with the internal and external use of antiseptics, is acting on 
false principles ; his practice may have the sanction of time, but it 
has not the support of observation and experience. In the early 
stage of the disease, when the cheek is of a deep red colour, tense, 
prominent, and shining, I do not know of any means which tend 
so directly to diminish the amount of inflammation, and check the 
progress of gangrene, as the application of leeches, few in number, 
but frequently repeated. This is the mode of treatment which I 
have found to be most effectual, and which, from my experience of 
the disease, I can recommend as the most Ikely to prove beneficial, 

* [Especially measles, — Ed,"} 



AGUE CAKE. 185 

when, unfortunately, the ordinary resources of medicine are too 
often ineffectual. 

With respect to internal remedies, Dr. Cuming lavs great stress 
on the utihty and value of purgative medicines. They may be 
certainly necessary, and as the little patients very often swallow the 
sanious discharge from the ulcer, more or less derangement of the 
intestinal canal must accompany the disease. But along with pur- 
gatives I would strongly recommend the use of sulphate of quinine, 
either in the form of enema, or if the child can be got to swallow 
it, made up into a syrup, and its solution favoured by. the addition 
of a little sulphuric acid. With regard to the external applications, 
you have a choice of many remedies, each of which you will find 
recommended by authors, but none of which can be exclusively 
relied on in any case. The balsam of Peru with castor oil forms a 
good application, or you may blend it w^ith honey, as we did in 
this case — one ounce of the balsam to two ounces of honey. You 
may also employ washes composed of solutions of nitric or muriatic 
acids, or of the chlorides of soda or lime. 

In the present instance the sore has, in spite of all our efforts, eat 
its way from the internal to the external surface of the cheek. On 
Saturday, the centre of the cheek was characterized by the appear- 
ance of a blueish-black spot, indicating the occurrence of sphacelus. 
In the meantime it was curious to observe how little constitutional 
disturbance was yet produced; the child, notwithstanding the ma- 
nifest existence of extensive sphacelation of the cheek, continued 
for several days to have a tolerable appetite, and to sleep well, being 
nearly free from fever, and complaining but little ; as the mortifi- 
cation progressed, destroying rapidly the external parts of the 
cheek, &c., matters soon altered, and the poor little patient sunk 
exhausted and suffering. 

Let us now direct your attention to the case of a sailor who has 
recently been discharged. This boy was one of the crew of a vessel 
which returned lately from the West Indies, and was exposed to 
great hardship during his voyage. Boys in his situation suffer an 
enormous quantity of fatigue and rough treatment ; they are the 
drudges of all on board, and it is impossible to conceive what pri- 
vations they endure. When the vessels arrive in unhealthy cli- 
mates, they are generally the first who fall victims to the prevailing 
malady, and such was the case of this lad, who got yellow fever 
immediately after his arrival at the West Indies. From this he 
recovered, but on his way home was attacked with irregular inter- 
mittent which lasted for a considerable time. He had no treatment, 
and the disease subsided spontaneously, leaving him extremely 
weak and emaciated. He was, however, obliged to work as usual 
on his passage, and he arrived in Dublin about three weeks since, 
debilitated, thin, and with a countenance expressive of long-con- 
tinued suffering. He had on his admission that peculiar hue of 
skin which often follows tedious intermittents, and which those 
who have once seen will always recognise with facility. This 

IG* 



]86 GRAVES'S CLINICAL LECTURES. 

colour is to be distinguished from the hue of slight jaundice — it is 
what has been termed a clay colour. In the present instance it was 
mixed with a faint tinge of jaundice, and on examining the stools 
we found that they contained scarcely any bile. He had no fever; 
his pulse was rather slow and regular; he complained of lassitude; 
his urine was deeply tinged with bile ; and his belly tumefied. On 
examining him, we found that the abdominal tumefaction did not 
depend on the presence of fluid in the peritoneum ; it was produced 
by enlargement of the liver and spleen, intestinal congestion, and 
tympanitis. 

Here was a case of what has been vulgarly termed ague cake ; 
that species of congestion and enlargement of the liver and spleen 
which is apt to accompany the paroxysms of an intermittent, and 
in some cases to remain after the disease has subsided. You are 
aware that some persons, during the paroxysms of an intermittent, 
will complain of pain in the right hypochondrium, but more fre- 
quently in the left, and on examination the liver or spleen is found 
increased in size. If you take the trouble of reading the experi- 
ments which have been made with the view of illustrating the 
functions of the liver and spleen, you will have a good idea of the 
facility with which enlargement of these organs, but particularly of 
the latter, may take place. The spleen undergoes very remarkable 
changes, even in its natural stale, during the process of digestion, 
and there is a great difference between its size when an animal is 
fasting, and its size when an animal has taken food. Indeed, it is 
surprising how rapidly it will become filled with blood, and how 
quick the transition is from a state of collapse to a state of con- 
gestion. It is easy, therefore, to conceive how the spleen may, 
during the paroxysms of an intermittent, particularly in the cold or 
congestive stage, become manifestly enlarged. The increase of 
size, however, never occurs to such an extent in the liver ; unlike 
the. spleen, its magnitude remains nearly the same, and its volume 
does not vary like that, of the spleen with the time of day or the 
period of digestion. It is obvious, therefore, cl priori, that the 
spleen should be more frequently the seat of congestion than the 
liver, and that its enlargement should be more distinct and palpable. 
But it is not in the liver or spleen alone that congestion occurs 
during an aguish paroxysm, it may take place in any organ ; and 
this, in a practical point of view, is worthy of being borne in mind. 
Thus, in a case which I attended, the patient got intermittent of a 
tertian type; during each paroxysm he had some distress about 
the chest and slight cough, but these symptoms disappeared during 
the intervals. As the disease, however, went on, the fits of cough- 
ing and dyspnoea increased, and the sulphate of quinine failed in 
arresting the paroxysms. The pulmonary congestion became gra- 
dually more marked and permanent, and no longer disappeared 
during the intervals ; finally, inflammation of the lung took place, 
and the patient died with extensive hepatisation. This happened 
about twelve years ago, when the old notion of connecting the cold 



AGUE CAKE. 187 

stage of ague with debility was universally nj'evalent, and before 
the practice of bleeding for the relief of visceral engorgement had 
been introduced. Subsequently, the practice of bleeding in the 
cold stage, as introduced by Dr. M'Intosh, was tried on an exten- 
sive scale in the Meath Hospital, and it is a practice which I can 
strongly recommend in those cases where there is recurring inflam- 
mation of some^internal organ. It is not a mode of treatment appli- 
cable to all cases, and in mild cases unaccompanied by excessive 
congestion of any viscus, it is totally unnecessary ; but where an 
important organ is threatened, it is a valuable remedy, and has on 
some occasions cut short the paroxysms altogether, or rendered 
them much milder and more manageable. 

Sometimes ague is accompanied by symptoms of congestion and 
inflammation of some internal organ during the paroxysms; and 
yet, by giving sulphate of quinine, you will succeed in arresting 
the intermittent and the visceral disease at the same time. I recol- 
lect the case of a boy who was under treatment here for ague, and 
who, during the paroxysms, had severe bronchitis with dyspnoea. 
The cough did not leave him even duriifig the intervals, but it was 
much milder; I was, however, doubtful whether the case would 
admit of the exhibition of sulphate of quinine, from the violence 
of the pulmonary symptoms during the fits. I determined, after 
some time, to try the quinine, and I found that it stopped both the 
intermittent and the bronchitis. It is to be observed, however,, that 
in this case the bronchitis was of a chronic character ; and I believe 
that in all cases of ague accompanied by visceral derangement, 
where quinine succeeds in curing the disease, the inflammation is 
either of a trifling description, or is one of a chronic nature. Where 
the visceral derangement is great, quinine will not succeed, and hence 
it is of great importance, in the treatment of ague, thai you should 
carefully attend to the state of the internal organs.^ 

There are several forms of disease which simulate intermittent 
in a very remarkable manner ; and, as this may lead to very danger- 
ous errors, it is necessary on all occasions to make a strict inquiry 
into the origin and- history of the complaint. Some forms of hectic 
assume the intermittent character, and have been frequently mis- 
taken for ordinary ague. Of this I had lately a very striking 
instance in the case of a lady, who came from the country of Lime- 
rick to consult me for what was stated to be an attack of irregular 
intermittent. She had been confined in August; had been feverish 
after her accouchement — the consequence, she believed, of exposure 
to cold — and got a slight cough. This continued, but without any 
expectoration, for two or three weeks, and then she was attacked 
with fever of an intermittent character, and exhibiting a well- 
marked tertian type. She began to take quinine, but this aggra- 
vated the cough very much without having any effect on the 

* [Iodine used internally and externally is often a good adjunct to quinine. 



188 GRAVES'S CLINICAL LECTURES. 

paroxysms. Various other remedies were also tried, but their only 
effect was to render the paroxysms more frequent and irregular. 
The moment I saw her I was convinced that she was labouring 
under some visceral disease. I examined her chest, and found dul- 
ness under the right clavicle with tubercular crepitus. Her cough 
had been dry until she came to Dublin, but now it became suddenly 
moist, and a distinct gargouillement could be heard. The apparent 
intermittent was nothing more than phthisical hectic ; and Dr. 
Stokes, who was also called in, came to the same conclusion. I 
recollect having observed something of the same kind in a case 
which I attended some time ago with Dr. Marsh. The patient had 
well-marked intermittent, and we treated him for it; but the sul- 
phate of quinine, and the other remedies which we employed, had 
only the effect of converting the fever into remittent. On a sudden, 
the gentleman, without having made any complaint of pain in the 
side, or anything indicative of derangement of the liver, became 
suddenly jaundiced, and sank rapidly. On dissection, we found 
seventeen or eighteen small circumscribed abscesses in the sub- 
stance of the liver. The intermittent hectic here depended on 
interstitial inflammation of the liver — a disease which is generally 
of a latent and incurable character. 

I need not refer here to certain forms of fever which accompany 
disease of the brain and of the urinary system, and which are 
remarkable for their intermittent character. There is, however, 
one form of anomalous intermittent, of which it may be necessary 
to say something : I allude to that species of ague which seems to 
be exclusively confined to females of a nervous habit — at least I 
have never met with it in any others. Persons of this description,^ 
after an accouchement or some acute disease, or in consequence of 
violent mental emotions, will sometimes get into a peculiar state of 
health, in which they are liable to recurring periodic attacks of 
fever. Some time since. Dr. Stokes called me to see a lady who, 
shortly after her confinement, had got an attack of well-marked 
tertian. She had, at the regular time, severe rigors, followed by 
acceleration of pulse, heat of skin, and profuse sweating. When 
the paroxysm was over, she felt tolerably well, but still there was 
much excitement of pulse, and the intermissions were anything 
but perfect. Sulphate of quinine had been tried by the accoucheur 
in attendance, but had failed. On examining the case, I found 
that the lady was of a decidedly nervous and hysteric habit, and 
advised the use of nervous and antispasmodic medicines. A mix- 
ture containing musk, camphor, and ammoniated tincture of vale- 
rian, was prescribed, and the intermittent symptoms rapidly dis- 
appeared. 

But to return to the case of this boy. How are we to treat this 
ague cake? The disease has not as yet proceeded so far as to 
produce ascites, but if permitted to run on it would soon cause 
effusion into the peritoneal cavity. In a case of this kind a great 
deal will depend on whether there is any fever present or not. If 



AGUE CAKE. 189 

there is no remarkable excitement of pulse or heat of skin, general 
antiphlogistic means will be unnecessary, for any local tenderness 
or irritation can be relieved by local bleeding. In the case before 
us, there was a slight degree of tenderness, and we applied leeches 
once with benefit; but we did not apply them over the abdomen — 
they were applied to the anus, because it is well known that leeches 
applied in this situation hatre a remarkably good effect in removing 
intestinal congestion, and consequently in relieving hepatic engorge- 
ment. Those who have remarked the relief which a flow of blood 
from piles gives in cases of hepatic engorgement with dyspepsia, 
will recognise the value of depletion of this kind, and will imitate 
the natural mode of relief by art. Hence the use of leeches applied 
to the anus in cases of intestinal congestion and hepatic or splenic 
engorgement. There is no necessity here for applying a great 
number of leeches — three or four every second day will be quite 
sufficient, and we have found this number answer every necessary 
purpose. In addition to local bleeding and attention to diet, I or- 
dered this lad to take a few grains of blue pill once a day, not with 
the intention of affecting his system, but merely with the view of 
keeping up the free action of the bowels. I continued the mercury 
only as long as the tendernessof the liver remained; for experience 
has shown, that in those cases of ague cake where there is merely 
enlargement of the liver without tenderness, mercury is a bad 
remedy. 

In cases of this kind, where the stage of active congestion is 
past — where there is no fever — where the tenderness is removed, 
and nothing but the increased size of the liver remains — how are 
you to accompHsh a cure? — first, by inserting one or two setons 
over the liver : and, secondly, by the use of iodine and tonics. 
The use of setons in cases of this description is well known, and 
needs no comment. I recollect the case of a lady, who, after seve- 
ral attacks of jaundice, got chronic enlargement of the liver. The 
right lobe of the liver, which was the portion chiefly affected, 
extended down towards the crest of the ilium, and was excessively 
indurated. This state had occurred after the patient had used 
mercury and been copiously salivated. Two setons were inserted 
over the region of the liver, and these produced rapid diminution 
of the enlargement, and a perfect cure. 

With respect to tonics, I may observe that they prove extremely 
useful in chronic enlargements of the liver and spleen. We are in 
the habit of using, in this hospital, a combination somewhat similar 
to the celebrated Bengal spleen powder ; it consists of vegetable 
and mineral tonics, combined with a vegetable purgative — as, for 
instance, aloes — and we have seen the best results from its use. 
With respect to iodine, it is a valuable adjuvant in such cases, par- 
ticularly where the system has been much deranged, and where 
mercury would be likely to run down the patient. Here iodine 
gives vigour to the constitution, and tends in a very remarkable 
manner to promote the absorption of the morbid products, on which 
the enlargement chiefly depends. 



190 GRAVES'S CLINICAL LECTURES. 



LECTURE XVI. 

It is my intention in this clay's lecture to refer briefly to some 
cases worthy of your attention ; I shall not dwell long on them, as 
I wish merely to point them out that you may observe them more 
accurately. 

In the first place, there is a man, named Yero, in the fever ward, 
■whose case I beg you will study with attention. He applied for 
admission here some time ago, labouring under violent and general 
bronchitis, accompanied with high inflammatory fever ; we took 
him in at the time, as his case w^as one of the most urgent danger, 
but were obliged, by the crowded state of the hospital, to put him 
into the large fever ward. It is unnecessary for me to detail the 
treatment employed, as you have all witnessed it. By the most 
energetic measures, w-e succeeded in arresting the disease, but his 
convalescence was rendered tedious in consequence of his having 
been suddenly affected by a small quantity of mercury. His mouth 
became very sore, his breath fetid, his gums spongy, the inside of 
his lips covered with lymph, and his system exhibited all the marks 
of mercurial irritation ; but, under the care of Mr. Grady, a gradual 
but decided improvement in his condition was going on, and he 
was advancing rapidly in convalescence, w^hen, unlucky for him- 
self, he was persuaded to leave the hospital for the sake of voting 
at the city of Dublin election. In doing this, he was necessarily 
much fatigued, and was exposed to cold on returning from the 
heated booth. !Xow, mark the consequences of this indiscretion. 
This man, just arrived at the period of convalescence from a severe 
and dangerous inflammatory fever, and greatly debilitated both by 
the disease and the venesections and other remedies necessarily em- 
ployed, improvidently exposes himself w^hile his frame was still 
emaciated and weak, and while his mouth was still sore in conse- 
quence of severe mercurial salivation ; in this condition he exposes 
himself to the operation of mental excitement, great bodily fatigue, 
and cold — and what have been the consequences? Why, that a 
new attack of fever immediately struck him to the ground with a 
heavy hand, and, after an absence of ten days, he returned to the 
hospital on the 24th of January, complaining of rigors, and other 
symptoms indicative of commencing fever. We saw him next 
morning, that is, before this new fever had lasted twenty-four 
hours, and we found him afl^ected in a most remarkable manner ; 
we found him labouring under a number of severe symptoms, 
which would have led the most experienced, if asked to guess how 
long his fever had already lasted, into the commission of a gross 
error, for he would answer that it must be at least the eleventh day. 
It is, indeed, very rare to find fever at once commencing with 
symptoms such as we observed on the first day in Vero. Great 
prostration of strength, hot skin, dry tongue, pulse lOS, nervous 



NERVOUS FEVER. 191 

agitation, restlessness, together with subsuUus tendinum, were 
present from the commencement. The subsuUus was very re- 
markable, and increased to such a degree, even on the second day, 
that Mr. Grady found it very difficult to count the pulse at the 
wrist ; and yet, though his muscular system was thus irregularly 
excited, and its nervous influence deranged, he had not even a ten- 
dency to delirium, and he slept soundly; neither had he the least 
headache. 

I called your attention to this circumstance at the bedside of this 
patient, and I endeavoured to impress strongly on your minds how 
forcibly this case opposes the doctrines of those who attribute all 
the nervous disturbance of every part of the system, and, among 
the rest, subsultus, to congestion or to inflammation of the brain. 
When the subsultus had attained a degree of violence in Vero's 
case, such as we seldom witness, we remarked, nevertheless, that 
he slept well, had a clear eye, without the least approach to suffu- 
sion, and that he was free from headache, heat of scalp, or throb- 
bing of the temporal arteries. Neither were we able to detect the 
slightest indication of inflammation, or even of congestion, in the 
chest or abdomen. The breathing was indeed quickened, but only 
in proportion to the acceleration of the pulse, and there was no 
cough or thoracic pain or uneasiness. The belly was fallen, soft, 
and quite free from tenderness; and there were no griping pains, 
flatulence, nausea, or diarrhoea, and yet the patient was evidently 
very dangerously ill. Agitated wilh subsultus, he was in a constant 
state of restlessness when awake ; his skin was hot, his tongue dry, 
and his weakness was sudden and excessive; in short, he was la- 
bouring under intense nervous fever. This is a rare form of disease, 
and one the very existence of which most modern pathologists have 
been in the habit of denying; but, as I told you in a former lecture, 
1 have seen several examples of it. 

I may remark that, in the presenT epidemic fever, the termination 
of the disease by a well-marked crisis never occurs. Now, in the 
epidemic fever of which I have spoken in a former lecture, and 
which committed such devastations in 1837, a crisis was observa- 
ble in the majority of the cases, and was almost always preceded 
by rigors and a hot fit, attended for a iew hours with marked exa- 
cerbation of the symptoms, and followed by a most profuse, warm, 
general perspiration, bringing perfect relief, and often so excessive 
that the steam of it could be seen issuing forth in vapour through 
the blankets in which the patient lay wrapped. In the beginning 
of the epidemic, the critical rigor often took place on the fifth 
day, and oftener on the seventh, but, as the disease continued, 
these short fevers, which, by the by, always left the patient very 
liable to relapse, entirely disappeared; and when the epidemic 
reached its acme, the crisis rarely took place so early as on the 
eleventh day, and most general on the fourteenth or seventeenth 
day. 

You perceive, that in judging of the truth of the doctrines held 



I 



192 GRAVES'S CLINICAL LECTURES. 

by the ancients, concerning the existence of critical days in fevers, 

an observer of the present epidemic might be led into error, and 
might, by generalising too hastily, arrive at the false conclusion, 
that this doctrine of critical days is totally destitute of foundation. 
But to return to our patient Vero. It is not very difficult to ex- 
plain why, in him, the moment fever was excited it assumed the 
nervous type. He had been debilitated by severe inflammatory 
fever and by active antiphlogistic treatment, and, above all, his 
nervous system had been severely tried by an unexpected mercu- 
rial salivation, brought on by an unusually small quantity of 
calomel. 

You are aware that various nervous symptoms attended with 
irregular muscular action, and simulating chorea, or paralysis 
agitans, are frequently the result of metallic salts, whether lead or 
mercury. For this reason, I look upon the previous mercuriaHsa- 
tion as the chief cause of the nervous typeof Vero's fever. In spite 
of all our efforts, he died exhausted on the tenth day. 

Let me now refer you briefly to the case of Catherine M'Donnel. 
This ^irl is labourinor under an attack of chorea of considerable 
standing, and is at present about fourteen years of age. I mention 
this because it is not improbable that the appearance of the cata- 
menia, which frequently come on about this period, may have some 
influence on the future progress of her complaint. She states that 
her disease commenced about seven years ago, and that ever 
since she has been subject to its attacks at various times. Her 
health is somewhat impaired, but not, however, to such a degree 
as to prevent her from Ibllowing her usual avocations. Her pre- J 
sent attack commenced about three weeks ago. ■ 

It is unnecessary for me to enter into any description of the con- 
vulsive motions of the limbs, and other symptoms which charac- 
terise chorea; neither is it my intention to enter into the general 
history of the di-sease; you will find an admirable account of its 
symptoms, pathology, and treatment, in Copland's Dictionary. I 
shall merely remark, with reference to this case, that there is no 
headache, and an accurate examination has failed in detecting any 
symptoms of determination to the head. Neither have we derange- 
ment of muscular motion during sleep ; the girl's sleep is tranquil 
and regular. There is no evidence of gastric derangement present. 
She relishes her food, and, what is rather singular, her appetite is 
better during the attacks than during the intervals. Her tongue is 
clean and moist, but her bowels are inclined to constipation. It is 
of importance to bear in mind here, that her symptoms do not ap- 
pear to have any connection with cerebral or gastric derangement. 
She has no headache, flushing of the face, noise in the ears, or 
throbbing of the temporal arteries, and there is nothing but consti- 
pation to show that the digestive organs are out of order. I dwell 
on these two circumstances particularly, because some persons 
have attributed chorea to cerebral irritation, and others to indiges- 
tion and gastric derangement exclusively. I am quite ready to 



CHOREA. . 193 

grant that it may be produced occasionally by either of these two 
causes, and that the presence of either will tend to aggravate it, but 
am inclined to look on chorea as chiefly a nervous disease, and to 
be cured chiefly by nervous medicines. Dr. Copland's remarks 
upon this question are excellent, and deserve to be attentively studied. 
For my own part, I think that in this, as in many chronic diseases 
where indigestion exists, it is often a consequence, not a cause, and 
is produced by debility of the vital powers of the stomach and in- 
testines, organs which are affected by causes acting on the whole 
organization. Thus a too rapid growth, premature or unnatural 
sexual indulgence, confinement, want of exercise, of rest, care and 
anxiety, &c.j may each occasion a weak state of every organ of the 
body, including debility of the stomach. In a girl of this age, who 
labours under constipation, it is always proper to commence with 
the use of purgatives, and I have accordingly ordered her some 
pills, composed of aloes and capsicum ; but I would not persevere 
in the purgative plan any longer than was necessary for removing 
constipation. What I mainly depend on for removing the disease 
is tonics, one of the best of which is the carbonate of iron, in doses 
of half a dram four times a day. There is at present a controversy 
between Dr. Billing and Dr. Johnston, with respect to the doses of 
carbonate of iron to be employed in this disease; and it is asserted, 
that in cases where doses of half a dram, three or four times a day, 
■will not succeed, a cure may be effected by giving three, four, or 
even five drams, frequently in the day. With regard to this sub- 
ject, I must confess that I am for moderate doses, and I think, in 
general, as much good may be accomplished by half a dram or a 
dram, three or four times a day, as by much larger doses. I have 
accordingly ordered this girl lo take half a dram four times a day, 
and will persevere in the use of the remedy until we have given it 
a fair trial. The carbonate of iron tends, in general, rather to pro- 
duce a relaxed than a constipated state of the bowels, and conse- 
quently is pecuUarly well adapted to chronic cases of debility. The 
mistura ferri aromatica, in moderate doses, is another excellent 
formula. When we have to deal with constitutional weakness, 
which has arisen gradually, and continued long, we must trust 
more to the operation of general physical influences than to medi- 
cine, and in graduating the doses of tonics, we must remember that 
it is impossible in such cases suddenly to strengthen ; we must, 
therefore, rely upon the gradual operation of tonics, given for a long 
continuance, and in moderate doses. This rule should never be 
lost sight of in the treatment of chronic diseases ; important as it 
is, most practitioners seem little influenced by it, or perhaps they 
are altogether ignorant of it, otherwise we should not see them 
using concentrated and powerful tonics- in such large and repeated 
doses in chorea. Another general rule as to the use of tonics in 
chronic diseases — usually you will be more successful with mild 
and diluted than with powerful and concentrated medicines. Thus, 

17 



194 GRAVES'S CLINICAL LECTURES. 

for example, cinchona in powder is often preferable to sulphate of 

quinine in chronic diseases.* 

There is a very curious case of paralysis agitans at present in 
the female chronic ward, which claims a few remarks. You must 
have all remarked the patient Ellen Davis, a young woman about 
twenty-five years of age. She has a most peculiar expression of 
countenance, and, as her disease is rather a rare one, I beg that 
any gentleman who has not seen it will take the opportunity of pay- 
ing her a visit. According to the account which she gives of her- 
self, the disease appears to have originated in a sudden and violent 
mental emotion. The poor girl, like most of the lower class of 
country people, happened to be a firm believer in the existence of 
ghosts and such like nonentities, and this superstition has formed 
the source or exciting cause of the disease in question. She was, 
unfortunately for herself, located in a very uncomfortable situation, 
her house being close to a road between two churchyards, a com- 
plete thoroughfare for ghosts, and where figures of a very question- 
able description had been frequently seen by many of her neigh- 
bours. Some of her acquaintances, who were aware of the frightful 
notions she entertained about personages of this kind, resolved to 
amuse themselves at her expense, and played oflT a practical joke of 
a very cruel nature. A churn-dash was procured, to which a sheet 
was appended, so as to form no unapt representation of a sheetec 
headless corpse, and this was dandled between two trees by meai 
of a rope. The poor girl, who happened to be going to bed at th( 
time, was utterly appalled by the sight of what she conceived to bef 
one of these ghosts sweeping through the air, and immediately' 
dropped down in a state of total insensibility. The fright derangedj 
her nervous functions in an extraordinary degree, she became ver-J 
tiginous, lost the use of her limbs on one side, and took to bed, froi 
which she states she did not get up for three months. 

The history of this case is of course extremely uncertain. Ii 
chronic cases, and among patients in her class of life, you can sel- 
dom expect to get an accurate or satisfactory account. It is quit< 
clear that she had hemiplegia, but whether it arose from the fright 
or not we ycannot exactly say. The symptoms of hemiplegia altei 
some time began to decline, and she gradually regained the powei 
of walking. T?his, however, is but feeble, and though it is nowj 
seven years since the occurrence of the attack, the muscular poweq 
oi the limbs is very shght. She had also during the progress of hei 
complaint an attack of amaurosis, which she says deprived he^ 
entirely of sight for nearly a year, and that after this period sh( 
recovered the use of one eye completely, but the other still remair 
amaurotic, and she can distinguish objects with it very imperfectly. 
At present she affords a very remarkable specimen of paralysis 

* [The black snake-root is an excellent remedy in chorea (adea, or clmicifuga 
raeemosa). Sulphur baths, or cold baths, either with fresh or, still better, salt water, 
are also very useful. — Ed.] 



PARALYSIS AGITANS. 195 

agitans. She cannot walk slowly, and when she has comntienced 
walking she cannot stop without considerable difficulty. The 
niuscles of the extremities, face, and tongue are very little under 
her control, and are in a state of almost perpetual motion. The 
muscles of the eyelids and eyeballs are also similarly affected, and 
this gives to her countenance a strange and peculiar expression. 
You will find an excellent description of this disease in Dr. Elliot- 
son's lectures; a very interesting case is also detailed in Dr. Wm. 
Stokes's lectures, published in Renshaw's London Medical and 
Surgical Journal. 

It would appear that in this disease the muscles are not by any 
means beyond the control of the will, but they are so influenced 
by the operation of some other unknown cause, that their motions 
are more or less imperfect and inadequate. She can walk quickly 
with tolerable ease, for in walking quickly the muscles are con- 
tracted more rapidly, and the will more strongly exercised, so that 
the obstacles to regular motion are in a great measure overcome, 
but when she walks slowly, time is given for the cause which 
produces the anomalous motions to come into play, a spasmodic 
state is established, and the muscles cease to obey the will so im- 
plicitly. I knew a gentleman who had a very curious form of this 
paralysis agitans. When about to walk, he was obliged to have 
himself balanced, and set off by some other person, just like a piece 
of machinery. When once set agoing, and on a smooth road, he 
went on very well for a considerable time, but if interrupted by a 
hill, or by the unevenness of the ground, he was compelled to run 
backwards in a right line until stopped by some one, and so little 
control of his motions had he at this time, that if a pond or preci- 
pice lay behind him he could not prevent himself from tumbling 
over it. I have occasionally seen him under such circumstances, 
and the appearance he makes is singular and ludicrous. He goes 
backwards until he meets with a wall or some other object which 
resists his further progress. This is a very curious circumstance 
as connected with the nature of the disease. 

I do not intend at present to enter into any inquiry respecting 
the nature and treatment of paralysis agitans. The prognosis of 
the disease appears to be, h priori, unfavourable, from the total 
want of any exciting cause which might be discovered and removed. 
If the disease consisted in congestion of the head or spine, or if 
there was any apparent lesion by the removal of which we could 
hope to effect some good, we might entertain a more favourable 
opinion with respect to its termination, but it unfortunately happens 
that in too many cases we can do nothing more than observe the 
curious phenomena which it presents. 

Let me now direct your attention to the case of a man named 
Murphy in the chronic ward, who came in with bronchitis accom- 
panied by anasarca. He had old bronchitic cough, copious expec- 
toration, and orthopncea ; but he had no symptom of disease of the 
heart : his pulse was regular and rather slow, he had also albu- 



106 GRAVES'S CLINICAL LECTURES. 

minous and scanty urine, but without any ferer, thirst, or nausea. 
The recent origin and sudden appearance of the disease induced 
me to look upon it as a case of acute dropsy, and I commenced 
the treatment by antiphlogistic measures, which, as you may have 
perceived, have been followed by remarkable benefit What I 
wish to call your attention to particularly in this case, is the state 
of the patient's urine. On his admission, we found that his urine 
was highly albuminous ; when submitted to the action of heat at 
the temperature of 170° it coagulated rapidly, and showed distinct 
traces of the presence of a large quantity of albumen. Yet under 
the use of opium in moderate doses this man's urine became in two 
or ihTBe days perfectly free from every trace of albumen, and has 
continued so ever since. 

Now this case alone would be a sufficient refutation of the c^- 
ttions of those who look upon albuminous urine as a pathognomic 
sign of disease of the kidneys, as described by Dr. Bright, and who 
are in the habit of marking such cases in the hospital as cases of 
" Bright's Kidney." It appears rather strange, as in our case, that 
a man should have " Bright's Kidney" to-day, and not have it the 
next day. We have had a great many instances of this kind, and 
in various cases which canie under our treatment in this bt^ital, I 
have shown that this state of the urine may depend oo mere fooc- 
tional disease of the kidney. Indeed, nothing is more common 
than to meet albuminfous urine in the drops}^ which succeeds scar- 
latina, and yet most of the patients perfectly recover. I had lately 
an opportunity of examining the kidneys of a boy named William 
Young, who was admitted into Sir Patrick Dun's Hospital on the 
sixth day from the comn^ncement of anasarca after scariatiaa. 
This boy's urine had a specific gravity as high as 1027, and con- 
tained an enormous proportion of albumen. He died suddenly of 
convulsions the fourth day after bis admission. His kidneys were 
in every respect healthy. 

One word with respect to the diuretic remedi^ wliich in this 
case I have employed with remarkable succe^. Having Fcsnoved 
the acute symptoms by antiphlogistic treatment, I presented the 
following decoction : — 

B Decocti hordei, J^j. 
Sacchari albi, 5j. 
Xitmtis pote-ssEB, ^ij- 

Acidi nitrici diluti, 5J- v., 

Spiritiis etheiis nitrosi, 5J. 

Two tablespoonfiils to be taken eveiy second hour. 

This is an excellent mixture, and well suited to the stage internie- 
diaie between the acute and chronic form of dropsj', where too 
wish to excite the action of the kidneys, and are afraid of stimukt- 
ing the system generally. It has acted very favourably in the case 
before us*, having increased the urinary discharge very coosideiabiT 
without producing any constitutional excitement. 

There is a roan at present in hospital labouring uoder diabetic ; 



DIABETES. 197 

he furnishes one of the best examples of the disease you can meet, 
and I would recommend you to study his case with attention. He 
has got the notion that his complaint is one of no ordinary interest, 
and he comes occasionally to remain awhile in hospital and exhibit 
himself to the class. It is unnecessary for me to enter into any 
general description of this affection ; you will find a very satisfac- 
tory account of it in the Cyclopaedia of Practical Medicine, and a 
shorter but equally valuable one in Dr. Copland's Dictionary. The 
most remarkable features of the disease are those connected with 
the change in the quality and quantity of the urine. With respect 
to the former, it is called mellitus when it contains a large propor- 
tion of sugar, and insipidus when it wants the saccharine taste, 
and presents nothing beyond a mere watery flavour. With regard 
to quantity, the change is very remarkable ; the man who is at 
present in hospital passes eighteen pints in the course of twenty- 
four hours. In the normal state a man passes about two or three 
pints; this therefore must be considered as an enormous increase. 

When you come to examine diabetic urine chemically, you find 
its specific gravity increased. Natural urine ranges from 1017 to 
1020, diabetic from 1020 to 1050. Now in every pint of urine of 
the specific gravity of 1030, there is contained nearly an ounce and 
a half of solid animal matter. If you took a pint of this man's 
urine, and exposed it to a temperature of 170° on an evaporating 
dish until all the watery parts were dissipated, there would remain 
at least an ounce and a quarter of solid animal matter. Now if 
you multiply this by eighteen, it will give you more than a pound 
and a quarter of solid animal matter, which this man loses in the 
course of twenty-four hours by means of the kidneys alone. I need 
not tell you that this is a very considerable loss, and hence it is 
that the man naturally calls for large quantities of food to replace 
it. And such is the nature of diabetes in general ; patients labouring 
under it have the activity of the digestive organs increased in pro- 
portion to the drain from their system : and were it not for this 
they would be rapidly run down by the emaciating effects of the 
disease. We notice this extraordinary activity of the digestive 
system in other diseases which have a tendency to produce ema- 
ciation ; thus a patient recovering from long fever will frequently 
take and digest with facility quantities of food which produce re- 
pletion in a state of health. 

In the case before us, one of the most remarkable things is the 
length of time the disease has lasted. The man has been now ill 
for more than three years ; it is nearly twelve months since he was 
here before, and at that lime he was just as bad as he is at present. 
He was relieved then, and went out of his own accord, and con- 
tinued since nearly in the same state we found him at his last ad- 
mission. He states that he has been ever since passing from twelve 
to twenty pints of urine in the day. He is, however, able to go 
about as usual, eats, drinks, and sleeps well, and, with the exception 
of the kidneys^ all his functions appear to be natural ; indeed, he 

17* 



198 GRAVES'S CLINICAL LECTURES. 

appears to be exceedingly active and vigilant ; he exercises a sys- 
tem of surveillance over the patients, nurses, and wardmaids, ex- 
poses all their sins of omission and commission, and might be now 
and then a very useful kind of person in a» hospital. 

With respect to the state of his skin, I may observe that it is by 
no means so dry, acrid, and harsh as we frequently find in diabetic 
patients ; indeed, it feels nearly natural, and is partially covered 
with moisture at various times of the day. Some persons, looking 
almost exclusively to the condition of the skin, have taken a very 
limited view of this disease. They consider it as arising from the 
perspiration being repressed and turned inwards on the kidneys. 
This, however, is by no means satisfactory. Some of the worst 
cases I have ever seen were accompanied by colliquative sweats. 
A gentleman came from the country last June to consult me for 
some affection of the digestive system ; on inquiring into his case I 
found that he was in the habit of passing very large quantities of 
urine. I took son'ie of it to my friend. Dr. Apjohn, to analyse, and 
it was found to be of the specific gravity of 1049. Now this gen- 
tleman had been subject to profuse perspirationS; and used at that 
very time to sweat copiously every day. In the case above stairs, 
the patient's breast and neck are frequently bedewed with perspira- 
tion. With respect to the opinions entertained concerning the nature 
of this disease, I beg leave to refer you to Dr. Copland's Dictionary ; 
for my own part I can form no idea of it, except that it is a 
functional derangement of the secreting powers of the kidneys. 
I look upon all those hypotheses which have sought to account 
for diabetes by referring it to derangement of the digestive organs 
as useless and unsatisfactory ; nor do I see why, in cases of disease 
we are to look for all the matters secreted by the kidneys in the 
blood. It is true that there are but few of the matters secreted 
by any glands in a state of health which may not be discovered 
in the blood. All or m.ost of the proximate principles of the mat- 
ters secreted by the salivary glands, liver, and kidneys, are to 
be found in the blood during a state of health, but in disease the 
case is quite different. Diseased vessels or parts may assume the 
function of combining animal principles in proportions and modes 
that form results differing in their nature from anything usually 
to be found in the system. I confess I can see no difficulty in sup- 
posing that a substance so simple as sugar is, may be formed from 
the elements of the blood, or that the vessels of the kidneys may, 
in a state of disease, take on a new action and secrete this substance 
with great rapidity. Sugar is one of those substances which are 
easily formed by nature, its elements are few and simple, and it 
may be formed with ease by beings belonging to the animal and 
vegetable kingdoms. From how many individuals of the vegetable 
class do we not procure it with facility ? How often do we meet 
it as an animal secretion ? Indeed, I have strong suspicions that 
a great many persons in society, who labour under what is merely 
considered in the light of indigestion, are affected with diabetes. 



DIABETES. 199 

This was the case of the gentleman whose urine was of the re- 
markably high specific gravity of 1049. He still continues to pass 
a larger quantity of water than natural, but not near so much as 
formerly ; its quality, however, has not improved so much as its 
quantity, and it still contains sugar. The state of health he enjoys 
is, with the aid of proper regimen and precautions, far. from bad, 
and he is enabled to discharge effectively the numerous duties 
attached to the agency of an extensive estate in the county of 
Carlow. Dr. Marsh, who has paid much attention to this subject, 
attests the prevalence of chronic diabetes in a mild form. It is to 
be feared that many cases escape detection, because the quantity of 
water voided by the patient being but little increased, the idea of 
diabetes does not suggest itself to the mind of the physician. With 
regard to the quality of the urine, I may here remark, that diabetes 
may be divided into two sorts : the first includes those cases in 
which the quantity of urine is increased, but its specific gravity is 
less than natural ; this comprises hysterical and nervous varieties 
of increased flow of water : the second, and to which indeed the 
term diabetes ought properly to be restricted, embraces those cases 
where the urine contains an animal principle either not naturally 
found in it or found in increased quantity. To this belong diabetes 
with sugar, with albumen, and with urea, viz. — diabetes mellitus, 
diabetes albuminosus, diabetes ureosus. The latter is by far less 
common than the other varieties. I have not myself met with an 
example, but it has been described by Dr. Bostock and others. The 
albuminous diabetes is often associated with dropsy, which latter 
attracts the chief attention of the physician. In some cases, however, 
the dropsical swellings are either very slight or altos:ether absent, 
while the urine is much increased in quantity, and highly loaded 
with albumen. A remark with respect to dropsy was suggested to me 
this morning by one of the cases in our chronic ward, and, lest I 
should pass it over hereafter, it may be as well to introduce it here. 
Dropsical effusion is in every instance produced by diseased action 
in the vascular system, and is the result of a morbidly affected 
secretion on the part of the extreme vessels. Now, like every other 
product of secretion, the effused fluid is liable to undergo great and 
sudden variations as to its quantity, variations produced by corre- 
sponding changes in the vascular or in the nervous system, which 
latter is so intimately associated v;/ith the function of secretion. 
This circumstance it is which occasions the swollen parts in ana- 
sarca to vary so continually in chronic cases of this disease, one 
part appearing more cedematous and again subsiding on the mor- 
row. INow dropsical patients are morbidly attentive to everything 
that passes, and are constantly dwelling on all the particulars which 
relate to their swellings. In hearing their report of themselves, 
you must not, therefore, allow yourselves to be misled, and you 
must never attribute any great importance to these local changes, 
which are too often merely temporary. But what I want to fix 
your attention on at the present is the fact, that the dropsical effu- 



200 GRAVES'S CLINICAL LECTURES. 

sions to which internal organs are liable are subject to similar unac- 
countable changes, whether of increase or diminution, and that 
from day to day in some cases. Thus an anasarcous patient will 
complain of having spent a wretched night, on account of cough 
and difficulty of breathing. You find his face, neck, and the inte- 
guments of the chest very oedematous ; and, on examining his 
chest, great dulness is found in one lung, w'ith moist crepitus; 
great oedema of that lung in fact exists. In a day or two after, and 
without any assignable reason, you find that the external oedema 
has much diminished, and that your patient, free from dyspnoea, has 
slept comfortably. You examine the chest, and you find a corre- 
sponding subsidence of the pulmonary infiltration. The same 
capricious increase or diminution is observed also in other secre- 
tions, as, for instance, in that of the bile. 

I have lately examined with much attention the figured large 
and solid fecal evacuations of a jaundiced geatleman, and observed 
more than once that one ,portion of the fecal cylinder was quite 
brown and thoroughly impregnated with bile, while the remainder 
was perfectly destitute of it, and therefore, was clay colourede. 



LECTURE XVIL 

There is a patient, named Catherine Corbally, in the Chronic 
Ward, to whom I would direct 3'our attention ; she is not seriously^ 
ill, but there are two circumstances connected with her case worthy 
of notice. She was an attendant in a family residing in town, the 
mistress of which, a young and healthy lady, was attacked with 
symptoms of fever about three days after child-birth, and died. 
Her fever was irregular in its progress, and attended with rapid 
pulse, laboured respiration, early sinking of the powers of life, and 
an eruption which was supposed to be miliary. Shortly before her 
death I was called in to see her ; on examination, we found that 
the disease was malignant scarlatina ; the case was completely 
hopeless, and indeed I believe that almost every female who got 
scarlatina after childbirth this winter died, no matter what might 
be the mode of treatment employed. The true nature of the dis- 
ease, however, was not made known to the family until five or six 
days afterwards, when all the children and two maid-servants took 
it. It was also remarkable that a person residing in the house, 
who had laboured under scarlatina before, was attacked with bad 
sore-throat about the same time. I advert to this circumstance, 
because it is a fact, that persons who have had scarlatina before, if 
closely engaged in attending bad cases of the disease, are very apt 
to get sore-throat. I know^ several medical men to whom this 
happened, and the same thing occurred to myself not long since,, 
though I had scarlatina in the malignant form. 



SCARLET FEVER. 201 

Another circumstance connected with this case is, that the pa- 
tient complains of severe pain in one of her ears, accompanied with 
deafness. This occurrence is frequently observed in similar in- 
stances; the inflammation spreads from the fauces along the Eusta- 
chian tube, until it reaches the ear, and hence we find many cases 
of scarlatina attended with more or less lesion of the function of 
hearing. It is very probable that this girl also got cold, for there 
is a considerable degree of tenderness about the external ear and 
over the mastoid process. In a recent lecture delivered at the 
Meath Hospital, I impressed on the class the necessity of making a 
careful examination of the parts where earache occurs during the 
progress of fever ; it is very often a treacherous symptom, and you 
will find in the works of Abercrombie and Itard several cases in 
which it preceded fatal disease of the brain. I do not intend 
speaking on this subject at present, but the case before us puts me 
in mind of a form of otitis which is frequently met with, and on 
which it may be necessary to say something. Otitis, like conjunc- 
tivitis and inflammation of the tonsils, is very apt to attack persons 
of a scrofulous habit, and it is sometimes of importance to be able 
to distinguish this from the acute otitis, which comes on in a 
healthy person, as the latter is found sometimes in connection with 
disease of the brain, the former hardly ever. In scrofulous otitis, 
the means of diagnosis are drawn chiefly from the constitutional 
symptoms, the appearance of the patient, the obstinacy of the dis- 
ease, and the sudden manner in which it gets better and then bad 
again. I lately saw an excellent example of acute scrofulous otitis, 
in a young lady of a decidedly strumous habit, living in Eccles 
street, and whom I attended, together with Mr. Leech, of Parlia- 
ment street. She was attacked with violent earache, accompanied 
with some otorrhcea and tenderness of the external meatus, indicat- 
ing inflammation. The pain, however, was intense, and far greater 
than the degree of inflammation seemed likely to produce; it re- 
mitted, or nearly intromitted, coming on violently about the same 
hour every day, and continuing to occasion intense agony for a 
few hours. Low diet, fomentations, leeches frequently applied, 
cathartics, blisters, all failed to produce relief. The disease, 
finally, suddenly yielded to ten grains of sulphate of quinine, given 
daily. The difficulty in such a case consists in determining how 
long we ought to persevere in the antiphlogistic method, and when 
we ought to begin with tonics suited to the neuralgic portion of the 
disease, for, like scrofulous ophthalmia, scrofulous otitis is accom- 
panied by a degree of pain by no means proportioned to the 
violence of the inflammation. The acute healthy otitis generally 
comes on after exposure to cold ; it is attended with severe pain, 
and considerable tenderness of the parts about the ear, and runs its 
course in a comparatively short period. Now, how is this acute 
otitis in the healthy subject to be treated ? Recollect the disease is 
one of a very intense character; this pain is frequently agonising, 
and the tenderness and heat of the parts about the external meatus 



202 GRAVES'S CLINICAL LECTURES. 

are very great ; recollect, too, that it may, and sometimes does, 
usher in disease of the brain, and let your treatment be, therefore, 
prompt and energetic. Purge the patient briskly, put him upon 
low diet and antimonials, and apply leeches in successive relays to 
the external ears, and over the mastoid process. In scrofulous 
otitis, on the contrary, the antiphlogistic treatment, both general and 
local, must be more cautiously applied, and must be sooner laid 
aside to be succeeded by the exhibition of tonic remedies. The 
greatest care and attention, however, is necessary before we decide 
to pass from one mode of treatment to the other, and we must be 
well convinced that we have sufficiently guarded against the 
danger of the brain becoming engaged in the inflammation, before 
we change to the tonic treatment ; when we do, we must proceed at 
first cautiously, afterwards more boldly. Give the carbonate of 
iron, or the sulphate of quinine, watching its effects, and increasing 
the dose as you proceed ; and in this way you wall succeed in 
arresting the disease, and curing your patient. I w^ould, however, 
strongly impress upon you the necessity of caution; feel your way, 
be sure that there is no active inflammation present, watch the 
efl^ect of every dose you give; by doing this, you will not, as some 
have done, run the risk of inducing fatal symptoms. In many of 
these cases, it is hard to draw a proper line of distinction at first ; 
adopt, therefore, the safe practice, and, though the disease be of an 
intermittent character, defer the use of tonics until you have re- 
moved inflammation ; you only lose a little time, whereas, by 
having recourse to them at too early a period, you may do your 
patient irreparable mischief. 

I shall now speak of the case of Christopher Nolan, which I trust 
you have all watched with attention. When this man came into 
the hospital, his condition appeared to be completely desperate ; he 
has, however, not only rallied, but is now convalescing rapidly. 
It is unnecessary for me to enter into a detail of his case, as I trust 
you have all observed it through its different stages; I shall only 
remark, that on his admission he was labouring under fever of the 
worst character; his body was covered with maculse; he lay con- 
stantly on his back, and had low muttering delirium ; was unable 
or unwilling to answer questions ; his breathing was oppressed ; 
his pulse rapid, small, and failing : the powers of life awfully pros- 
trated ; in fact, he was in a state of apparently threatening dissolu- 
tion. 

My first object was to rouse the sinking powers of the system, 
and with that view I adopted the following treatment. He was put 
into a comfortable bed, and heat was restored to the surface by dili- 
gently rubbing his trunk and limbs with warm flannel. I next 
ordered a succession of flying blisters to the neck, chest, and abdo- 
men. I may observe here, that his chest was heaving, there was a 
general wheezing audible over the whole surface, and he had that 
peculiar livid expression of countenance, and dusky hue of skin, 
which indicate an imperfect aeration of the blood. With the view 



BLISTERS AND STIMULANTS IN FEVER. 203 

of stimulating the oppressed action of the respiratory nerves, I had 
two blisters applied, one on each side of the neck, above the cla- 
vicles ; after remaining on for two hours, these were removed, and 
two more applied over the supra-mammary region, then over the 
heart and right side of the chest, and lastly, over the epigastrium. 
In addition to this, he was ordered to have wine and chicken broth, 
and the following draught was prescribed, to be taken regularly 
every second hour until symptoms of reaction began to appear. 

Bi Misturse camphorse, ^j. 

Liquoris anodyni HofFmani, ^ss. 
Spirilus ammonisB aromatici, Jss. 
Moschi grana octo. 

In employing blisters in this case, my object was to stimulate 
powerfully, and in rapid succession, the integuments of the neck, 
chest, and abdomen. The practice has in such cases been attended 
with very marked effects, and in ours proved extremely valuable. 
Its efficacy seems to depend, not on the discharge of serous fluid, 
or on any revulsive action of the blisters, but on the powerful 
stimulus applied to an extensive cutaneous surface. I may observe 
here, that, during the present epidemic, blisters have been one of 
our most efficient means of cure. In several bad cases, I have 
blistered' the nape of the neck, the chest, hypochondrium, and 
nearly the whole of the abdomen, in succession, and often with 
remarkable benefit. In ordinary cases of fever, tenderness of the 
epigastrium, pain in the head, and derangement of the respiratory 
system, are best treated by the application of leeches, or even by 
the use of the lancet ; but in the present epidemic, I have observed 
that patients bear bleeding very badly, though practised at the 
commencement of the disease; and the same rule applies, though 
with less force, to abstraction of blood by leeches or cupping-glasses. 
As far as my experience goes, local or general depletion should be 
resorted to with caution. I am not timid in the use of the lancet 
or leeches, but I have seen several cases of fever which terminated 
fatally, and these were chiefly cases where venesection had been 
performed at the commencement of the attack ; and, with respect 
to leeching, I have found that those cases were very difficult of 
cure, in which, relying on my experience of former epidemics, I 
had leeched too freely for what I considered to be local congestion. 

With respect to the general employment of blisters in fever, it is, 
I believe, a prevalent but erroneous practice to leave them on much 
longer than is necessary. I seldom let them remain on longer than 
four or five hours ; I speak here of flying blisters, which are applied 
successively to the nape of the neck, inter-scapular region, chest, 
and abdomen. Sometimes two or three hours will be sufficient. 
It is true that a blister will seldom rise in this space of time ; but, 
though you have no serous discharge, the moment the skin under 
the blister becomes red, every purpose is accomplished ; if the 
blister be removed, and the parts dressed with spermaceti ointment, 



2m CSAVBSS CLDvIC Al LIT ? I ?. 

il wiffl rise is the cmass of a ■>. - Z : r 

two iaqKHtaatadvaolages aie c : ; e : — _ t 

rf bad sfMcs, and obviaie the r i 

caiitltairide& It is hi many : : r 7 2 

faBsier €Mi loo loi^ aod jei we 5 t t 

vsmaiB oo lor twdve^ eigfctsrr : : 

jou excite tbts v^sds of ir i 

proof spiiii, iM- oil of tcTT.? 

rise in threeorlbor Im:^ f : r - 

aiiamberofexpenineic:i H ? 

tainedlhat the tione nezrii r i 

is mocfa shorter tinafi is geii ; :r t: :; . i :::fij iraiee 

hours; in some, even t^c i;z::.iv ^ ' lE.fTerjr 

instance, the initatioii : ' ; : : .; z : t : : : : : i " 5 i ^ - ; ■ t ; :': jt 

hoan^ 

I hare staled that in : : :: ' r ■ 7 r ". t t : : t 

Widi re^5sct to the rei; _ : 7 : ; : ; 7 7 7 

pn^ent ^Mdecaicg a liz : : -7 7 : : 7 • : . 7 ■ : 

earij pmod of the dist 

in the habit of ^ving : i 

qpnntilies (^ wine. Ic 

tiraimed, bcdt of broth : : z'-- _ : r 7 7 

anoOl^r point with respect lo z 7 r 7 : t 

toimpress cm jocr '^ '^-T :- ' r i- 

fol in obserrix^ t2:7 7 : i 

which I limit the r .. ":i 

other mild ariicies i r r : 

^fat in the ev<es2'.:.z "7 ' : 7: : 

diall talie nntriaier: 7 ^ 

winch he is accss: : ^ : i 5 ~: ri.i " : 

aBow him noth'^r :_: -■ : iv i :: : : j i . / 

pefsoaded tiis: ' :: ~7 :"; ;i.7:; 17.. -7: " t 

ihis sioqiie plaii. 

A few words " i. with respect to the<^ sSimobnt 

z::z.:r-;s ~ : —7 7.' 'is case with snch remarikaye 

-.Zzi s 7 . ; r 7 : 7 :: i " ' 7 : ". 5?s dD^ztrines iidncfa atsriboled 
-.. 7 ^ i : r V : 77 i i : Janis ^ into neigject 

i ~ : ; : : 7 : . ; i : _ : :: : ~ 7 ; j i : ^ : 7 7 :} readl«ed more oer- 

: 1 . . : - ' 7 : i -75.5 7 . ; :^ : : ^ • . we hane ileained 



I 



DROPSY. 205 

nervous system, without having any tendency to produce cerebral 
congestion or coma. Unlike those remedies which powerfully 
affect the nervous system, it does not produce intoxication or nar- 
cotism. Hence it is that musk proves such a valuable stimulant 
in cases such as I have described, where there is reason to appre- 
hend congestion of the brain. At the same time that you prescribe 
musk, you should assist its action by blisters, judiciously applied. 
They may be applied along the sides of the neck, or over the 
chest, to excite the nerves of the heart, lungs and diaphragm; or 
you may apply them between the shoulders, and to the back of the 
neck, where your object is to act on the brain and spinal marrow. 
In cases like this, the best places for applying blisters are the neck, 
region of the heart, epigastrium, and spine. The blister should be 
small, and you should make up for their want of size by successive 
applications. 

I have only to add that the treatment adopted in this case suc- 
ceeded in again rousing the almost suspended powers of the system, 
the patient rallied, and his fever assumed a much more manage- 
able aspect. I was obliged, however, to have recourse to the tartar 
emetic mixture with opium, in order to produce sleep. This com- 
pleted his cure ; from the time of its exhibition, everything went 
on well. 

Two cases of dropsy, in the chronic ward, next claim our atten- 
tion. Both have occurred in persons who have previously enjoyed 
tolerably good health, and in both the disease seemed to be unac- 
companied by organic lesion of any important viscus. One of the 
patients, J. Austin, states that he has been ill two months before he 
came into hospital, and acknowledges that his illness was the result 
of long continued habits of inebriety. Careless and intemperate in 
his mode of life, and frequently exposed to cold and wet, he got an 
attack of bronchitis, accompanied by a sense of constriction about 
the chest, and difficulty of breathing. He was bled for this, and 
states that the bleeding relieved his dyspnoea ; but about this period 
he remarked that an anasarcous swelling appeared in his face, neck, 
and chest. 

In this case we have a specimen of the ordinary history of dropsy 
in this country: — first, intemperate habits, next, exposure to cold, 
followed by bronchitis or pneumonia, and then dropsy, commencing 
in the face, chest, and upper extremities. I have on a former 
occasion pointed out to the class the importance of observing in 
what part of the body the dropsical swelling first appears, because, 
by doing so, we obtain a more accurate idea of its nature, and are 
furnished with a clue towards discovering its source. Dropsy is 
generally the consequence of organic disease of some deep-seated 
viscus. When it is produced by thoracic disease, as bronchitis, 
pneumonia, or affections of the heart, it is said that the swelling 
always begins in the face, neck, trunk, and upper extremities ; when 
it depends upon chronic hepatitis, disease of the spleen, obstruction 
of the system of the vena porta, or disease of the mesenteric glands, 

18 



206 GRAVES'S CLINICAL LECTURES. 

the swelling commences in the abdomen, and then proceeds to the 
lower extremities ; but when it arises from mere debility, the con- 
sequence of hectic fever, long continued diarrhoea, or a cachectic 
state of the system, the effusion is first observed in the lower ex- 
tremities, coming on in the evening, and again disappearing towards 
morning. The history of dropsical swellings, therefore, by informng 
us in what part they first appeared, is often sufficient to indicate the 
general nature of the producing cause. 

When this man came into the hospital, his cough had disappeared, 
and there was not any unequivocal symptoms of disease of the 
heart, but he had considerable dropsical swelHng of the face, chest, 
and superficial parts of the abdomen ; his appetite was bad, and on 
examining his urine, we found it loaded with albumen, and of the 
specific gravity of 1029. Though he had no fever or dyspnoea at 
the time, we commenced the treatment by general bleeding, because 
he was a person of rather robust constitution, and on account of his 
dropsy having originated in cold. In persons who are able to bear 
bleeding, and where the disease has commenced in an acute form, 
you may often commence the treatment of dropsy by a single bleed- 
ing with great advantage, even though there be no fever or local 
inflammation present. We next prescribed an aperient injection, 
to be followed by a vapour bath. I then, by-way of trial, give him 
an electuary containing some diaphoretic medicines, and found that 
it acted v^-ell on the skin, and that sweating could be easily induced. 
This furnished me with a key to the after treatment. Whenever 
you find that sweating can be easily brought on in dropsical cases, 
you should obey the hint given by nature.* You should not, under 
such circumstances, have recourse to mercury, or hydragogue pur- 
gatives, or diuretics ; you are to open the passage which nature has 
pointed out, you are to encourage diaphoresis, and you may rely 
upon it that you will in this way effect an easier, safer, and more 
permanent cure than you could by any of the various modes em- 
ployed for similar purposes. We therefore gave this man a powder 
containing four grains of Dover's powder and five of nitrate of 
potash three times a day. The Dover's powder is tempered by j 
combining it with nitrate of potash, which is an antiphlogistic, ^ 
and prevents the former from exercising a heating efl^ect on the 
system. Having continued these powders for seven or eight days, 
we commenced the exhibition of opium, in doses of half a grain, 
four times a day, to be increased after a few days to half a grain 
every fourth hour. Under the use of vapour"baths used daily, and 
opium to the amount of three grains in the twenty-four hours, the 
man has improved wonderfully, and the dropsical swelling is fast 
subsiding. Opium has here, you may have remarked, produced 
no bad efl^ects. The tongue is neither dry nor furred, and it has 
not any of that appearance which is observed in persons who are 
in the habit of taking opium; his appetite is unimpaired, his bowels 
regular, and his strength undiminished. 

* [A highly practical remark, especially in anasarca. — Ed.] 



TREATMENT OF DROPSY. 207 

jNow why did I give opium in this case ? Tlie more advanced 
students will perceive that 1 have treated it nearly in the same way 
as I treat cases of diabetes : because 1 have taught, and have been 
the first to teach, there seems to be an analogy between chronic 
dropsy and diabetes, and because experience has proved to me that 
this mode of treatment is most likely to be attended with success. 
I shall not dwell on this point at present, as I have already pub- 
lished a paper on it in the Dublin Medical and Chemical Journal, 
to which I refer you, merely observing here, that opium and other 
diaphoretics increase strength, remove the dropsical swelling, 
diminish the quantity of albumen in the urine, and bring on con- 
valescence without producing any bad effects on the head or diges- 
tive system. Dr. Osborne, Dr. Gregory, and Dr. Bright, have 
asserted that the presence of albumen in the urine arises from a 
particular disease of the kidney, in which the whole texture of the 
organ is altered, it becomes hypertrophied, finally harder than 
natural, and of a pale yellowish colour. On the other hand, Dr. 
Elliotson, Dr. M'lntosh, and myself, have opposed this view of the 
question. It is true that this kind of kidney is sometimes found to 
exist with an albuminous state of the urine, but this is by no means 
invariably the case. I have seen many cases of albuminous urine 
which yielded completely to the exhibition of opium, and this surely 
could not happen if organic disease were present. And though the 
cases in which this has occurred are not very numerous, still the 
evidence is good, and it cannot be denied that such a state of the 
urinary discharge may, and does, depend on constitutional causes 
totally independent of disease of the kidneys. I have very little 
doubt that it is to such an origin the present case is to be referred, 
and I feel confident that we shall cure it with opiurn. I am 
anxious that you should attend to this case and watch the result, 
for the treatment is quite different from that employed by others. 
I say this without meaning to claim any originality ; but 1 may be 
permitted to say, that it is a mode diflfering very much from those 
generally pursued. It cannot be used in cases where fever or local 
inflammation is present ; but when the local and general excite- 
ment has been subdued, or when the case is chronic and unaccom- 
panied by quick pulse, or any symptoms of visceral inflammation, 
it may be employed with safety and advantage. 

The second case is that of the patient Matthew Gray, a man of 
middle age, and rather robust constitution. On adniission, he 
stated that he had been dropsical for about twelve days, and com- 
plained of cough, dyspnoea, constriction of chest, and feverish 
symptoms. His cough was hard, short, incessant, preventing 
sleep, and increased by every attempt at full inspiration. He had 
general wheezing, much oppression about the chest, and scanty 
expectoration of frothy mucus. His pulse was 84, soft and rather 
weak ; he complained of nausea and loss of appetite, and had 
cfidema of the lower extremities. On examining the chest, I found 
it sounded clear on percussion, and that the physical signs present 



208 GRAVES'S CLINICAL LECTURES. 

were those of bronchitis passing into the stage of supersecretion. 
In addition to this, there were symptoms of engorgement in the 
lower and posterior parts of the lung. 

Here, then, we had a case of dropsy supervening on acute bron- 
chitis. I therefore ordered him to be blooded immediately, and 
afterwards to have cupping-glasses applied over the congested part 
of the lung. The local abstraction of blood was followed by re- 
markably good effects : it relieved the cough and constriction of 
chest, and diminished materially the pulmonary congestion. I 
next prescribed the following mixture, of which he was directed to 
take one tablespoonful every hour. 

B Misture amygdalaram, o^ij- 
Antiraonii tartarizati granum, 
IS'itratis potassse, 5ij- 
Tincturee hyoscvami, 5'^* 
TinctuisE digitalis, 5ss. 

A mixture like this is well adapted for such a case, it removes 
the febrile condition of the system, and, by its demulcent and seda- 
tive properties, allays the cough and bronchitic irritation at the 
same time that it determines to the kidneys. Those medicines 
which are termed demulcent, are frequently of great value in the 
treatment of bronchitis; you will often derive more benefit from 
gum Arabic, spermaceti, almond emulsion, and the like, than from 
?my other class of remedies. In the present case, we combined 
them with sedatives and narcotics: and as the remedies prescribed 
under such circumstances should be antiphlogistic, we added a 
grain of tartar emetic and two drams of nitrate of potash. I have 
already spoken of the powerful antiphlogistic properties of a com- 
bination of tartar emetic and nitre, and dwelt on the benefits derived 
from it in many forms of inflammatory disease, so that it is unne- 
cessary for me to sa}^ anything at present on the subject. It is 
obvious to all, that the tinctures were added on account of their 
sedative and narcotic properties, tending to remove irritation and 
induce sleep, of the want of which the patient complained. But 
you ma}- ask me why I did not order opium : simply because the 
disease was in its acute stage, and at a period when opium is apt to 
produce excitement of the system, and aggravation of the local 
symptoms. Instead of opium, I gave hyoscy^amus, which neither 
increases heat, produces headache, nor checks expectoration ; and 
to this was added digitalis, a narcotic possessed of considerable 
antiphlogistic properties. Of all the narcotics, digitalis may be 
given with the greatest safety in cases where antiphlogistic treat- 
ment is required. 

It is unnecessary for me to follow up this case through all its 
details. It will be sufficient to state that, by gradual changing 
the nature of the treatment as inflammation declined, and particu- 
larly by the proper employment of powerful purgatives, I have 
succeeded in producing a rapid amendment in his symptoms. It 



TREATMENT OF DROPSY. 209 

may be, however, necessary to explain why I used purgatives, and 
in what way they were exhibited. In cases where extensive bron- 
chitis has given rise to pulmonary engorgement and dropsy, when 
you have reHeved the acute symptoms by bleeding, leeches, or 
cupping, and other antiphlogistic means, and wlien there only 
remain some wheezing, oppression of the chest, and rather copious 
expectoration, you will often eflect a vast deal of good by the judi- 
cious employment of powerful purgatives. You will clear the 
chest, relieve the breathing, and diminish the dropsical effusion. 
In the present instance, the patient took the following bolus : — 

R Pulv. jalapse — rhei — scammonise, aa gr. v. 
Elaterii, gr. ss. 

Bitartratis potass^e — sulphatis potassae, aa ^ss. 
Syrupi zingiberis, q. s., ut fiat bolus. 

This acted powerfully, and its operation was followed by marked 
diminution of the pulmonary engorgement and dropsical swelling. 
I have frequently endeavoured to impress upon the class the trutk 
of an observation made by Dr. Paris, that in the exhibition of 
remedies, much better effects are obtained by combining several 
analogous remedies in small quantities, than by giving a single 
one in a large dose. By combining substances which are of the 
same nature, that is to say, which are individually capable of exert- 
ing the same effect on the system, we are capable of producing 
more decided effects, even though these substances be given in 
diminished quantity, than if W'e prescribed any one ingredient of 
the combination in a full dose. I refer to this general principle, in 
order to explain W'hy I had recourse to so many different medi- 
cines, instead of employing a single powerful ingredient in con- 
siderable quantity. It explains why instead of giving at once 
fifteen grains of the powder of jalap, I gave five grains of jalap, 
five of rhubarb, and five of scammony, and added to these half a 
grain of elaterium, and a small quantity of cream of tartar and sul- 
phate of potass. With respect to elaterium, I may observe that it 
has been strongly recommended in those cases of dropsy where 
there is no irritation of the digestive system present. Its action on 
the intestinal tube is very energetic, and from the quantity of 
watery secretion which it generally brings away, it is of great 
utility in removing anasarcous swellings. 

These are the principal observations which I have to offer with 
respect to this case. I may mention, that as the patient complained 
much of restlessness, we prescribed half a grain of morphia, to be 
taken at bedtime. This succeeded in producing sleep, a most im.- 
portant point in the treatment of all acute affections. We have 
now omitted the use of the more powerful remedies, and have pre- 
scribed to-d^y a decoction of Iceland moss with tincture of opium, 
to act as a pectoral demulcent, and he has been allowed chicken 
broth and jelly. He is going on at present in a very satisfactory 
way, but it will be necessary to watch him carefully during his 

18* 



210 GRAYES'S CLINICAL LECTURES. 

convalescence, and obviate the occurrence of a relapse. If dis- 
charged at present, and before convalescence is perfectly esta- 
blished, he would in all probability relapse, and soon become much 
worse than ever. Hence I intend to keep him here for a month or 
six weeks. As long as I have been attached to public hospitals, I 
have made it a fixed rule, in all cases where a cure was possible^ 
to keep the patient until it was confirmed. Whenever I was 
obliged, under the pressure of urgent necessity, to dismiss a case 
before healthy action was completely re-established ; or whenever 
patients left the hospital prematurely of their own accord, I have 
observed that such persons, particularly if placed in the lower 
ranks of life, and subject to the numberless accidents and expo- 
sures of poverty, almost invariably returned in a far worse condi- 
tion than before. It is much better, though perhaps it does not 
make so striking an appearance in hospital returns, that a certain 
number of patients should receive all the benefits derivable from 
such institutions, than that a greater number should pass through 
them in the year, and be hurried out of them in a state of imperfect 
convalescence. Thi^ observation particularly applies to fever hos- 
pitals, and is, I fear, too little attended to in this city.. Certain I 
am, that a vast number of the cases of incurable pulmonary and 
intestinal disease which are admitted annually into the Mealh Hos- 
pital, have had their origin during the state of debility in which 
the patients were when dismissed from a i'ever hospitaL Improper 
diet, imperfect clothing, bad lodging, damp rooms, are borne by the 
constitutions of the poor with comparative impunity as long as 
they are in a state of health; but not so when ihey are debilitated 
by a recent attack of fever, treated or maltreated by active reme- 
dies, and dismissed from hospital in a week or ten days after the 
crisis has taken place. How injurious to persons so debilitated the 
change from the warmth and comfort of a hospital to the cold and 
desolation of a damp garret or cellar I Add to this, that n^iany of 
them,, at the time of their; discharge, still evidently bear the marks ^^ 
of mercurial action in their system, and many have their hair very m 
short, in consequence of the head having been shaved during their " 
illness. Hence many catch colds that aflfect the ears or eyes; 
hence many become deaf, and not a few^ get sore eyes; while the 
number of those in whom the sequelae of the fever rapidly induce 
incurable chronic diseases is so great, that, were the balance of the 
account to be fairly struck out, it would be found fever hospitals do 
less good to the pablic health than is generally imagined. 



i 



SCARLET FEVER. 211 



LECTURE XVIII. 



It is my intention to-day to make a few observations on the 
scarlet fever which now prevails as a destructive epidemic in 
Dublin, and many other parts of Ireland. The history of such 
epidemics is very interesting, and tends to shed much light, not 
only upon the changes which diseases undergo, but upon the fluc- 
tuations of medical opinions and treatment. In the year 1801, in 
the months of September, October, November, and December, 
scarlet fever committed great ravages in Dublin, and continued its 
destructive progress during the spring of 1802. It ceased in sum- 
mer, but returned at intervals during the years 1803-4, when the 
disease changed its character ; and although scarlatina epidemics 
recurred very frequently during the next twenty-seven years, yet it 
was always in the simple or mild form, so that I have known an 
instance where not a single death occurred among eighty boys 
attacked in a public institution. The epidemic of 1801-2-3-4, on 
the contrary, was extremely fatal, sometimes terminating in death, 
as appears by the notes of Dr. Percival, kindly communicated to 
me, so early a"s the second day. It thinned many families in the 
middle and upper classes of society, and even left not a few parents 
childless. Its characters seem to have answered to the definition 
of the scarlaiinamaligna of authors, for a description of which I 
beg leave to refer you to the Cyclopgedia of Practical Medicine, 
where you wnll find an article on the subject by Dr. Tweedie. In 
making this reference,, however, I do not wish to be understood as 
expressing my unqualified approbation of the article in question, 
for I must in candour confess that it falls far short of what we might 
have expected from a physician of Dr. Tweedie's learning and ex- 
perience. The long continuance of the period during which the 
character of scarlet fever was either so mild as to require little 
care, or so purely inflammatory as to yield readily to the judicious 
employment of an antiphlogistic treatment, led m.any to believe that 
the fatality of the former epidemic was chiefly, if not altogether, 
owing to the erroneous method of cure then resorted to by the phy- 
sicians of Dublin, who counted among their numbers not a few 
disciples of the Brunonian school; indeed, this opinion was so pre- 
valent, that all those whose medical education commenced at a 
much later period, were taught to believe that the diminished mor- 
tality of scarlet fever was entirely attributable to the cooling regi- 
men, and to the timely use of the lancet and aperients, remedies 
interdicted by our predecessors. This was taught in the schools, 
and scarlet fever was everv day quoted as exhibiting one of the 
most triumphant examples of the efficiency of the new doctrines. 
This I myself learned — this I taught; hov/ erroneously will appear 
from the sequel. It was argued, that had the cases which proved 
fatal in 1801-2 been treated by copious depletion in their very com- 



212 GRAVES'S CLINICAL LECTURES. 

mencement, the fatal debility would never have set in, for we all 
regarded this debility as a mere consequence of previous excessive 
reaction. The experience derived from the present epidemic has 
completely refuted this reasoning, and has proved that, in spite of 
our boasted improvements, we have not been more successful in 
1S34-5 than were our predecessors in 1801-2. 

Before I detail more particularly the symptoms that accompany 
the present epidemic, I wish to enter a little at large into the sub- 
ject of the changes and variations which the same disease is ob- 
served to undergo at ditferent periods of time. This is a topic 
which occupied some of the master minds of antiquity, and upon 
which the greatest of modern physicians, the illustrious Sydenham, 
bestowed considerable labour. It has been too much neglected of 
late, and consequently I consider it my duty to call your attention 
to it, and I cannot do this better or more forcibly than by commu- 
nicating to you a literal translation which I have made from the 
German of my friend Dr. Autenrieth's observations on this subject. 
The task of translation is always not only difficult but irksome ; 
but if, as in the present instance, I can by this means convey to you 
valuable information not before presented to my class, or to the 
public in English, I never decline the labour. What I am now 
about to read is, indeed, most important, and well deserves the deep 
attention of every practical physician. 

The third cause, connected with time and capable of modifying 
diseases, is of infinite importance, both in a theoretical and practical 
point of view, but has seldom attracted m.uch attention. Its exist- 
ence is attested by its effects alone, for its nature remains unknown. 
I allude to the constitutio morhorum stationaria, first noticed by 
Sydenham, but, since his time, nearly forgotten, or else confounded 
with the permanent influence of the seasons, or the accidental 
atmospherical changes spoken of above. All diseases, contagious 
and non-contagious, acute and chronic, (the latter, however, seldom, 
except when attended with some degree of general excitement,) 
have been observed to preserve a certain constitution or general 
character, which continues for a number of years in succession, 
with occasional interruptions, until it is displaced by another con- 
stitution of a different character. Thus, during one period, diseases 
are remarkable for being frequently accompanied by a sensation 
of extreme weariness, sudden sinking of the strength and vital 
powers, unpreceded by any evident marks of excitement, and at- 
tended by a disposition to pass into true typhus. During another 
period, the tongue is in general loaded with a thick white or yel- 
lowish coat, and many other symptom.s of derangement in the 
digestive organs, such as a bitter taste, costiveness, or diarrhoea, 
are constantly observed. 

During a third period, diseases are characterised by a remarkable 
degree of vascular excitement, an evident tendency to local deter- 
minations, a frequent formation of morbid productions; in a word, 
by all the symptoms of inflammation. 



SCARLET FEVER. 213 

It is not known whether the transition from one of these periodic 
constitutions to another takes place suddenly or gradually; but the 
latter supposition appears more probable, except when the transition 
is accompanied by unusually great atniospheric changes. The 
erysipelatous affection, which, both in England and Germany, suc- 
ceeded the gastric and accompanied the first appearance of the 
inflammatory period, seems to have been an example of the gradual 
transition. Accurate observations are still wanting to determine 
whether this periodic constitution is confined to certain parts of the 
world, or extends over the whole, and whether its different species 
follow each other in a regular order of succession. If their order of 
succession should at any time be determined, it will enable the 
physician to foretell the character and most appropriate treatnient 
of future diseases. The above question cannot be answered with- 
out very great labour spent in the investigation of the history of 
diseases in all ages and all countries, and are therefore foreign to 
the present work. 

The general indications of course vary with the nature of the 
prevailing constitution ; and, consequently, during one period 
stimulating remedies, during another alvine evacuations, and dur- 
ing a third venesection and the antiphlogistic plan, will constitute 
the most effectual treatment. 

This very circumstance has caused much confusion in medical 
opinions, and has occasioned the reputation and the downfall of 
many an infallible system, each of which is in its turn consigned 
to oblivion, and perhaps again revived as a novelty at some future 
period. The English boast much of the astonishing improvements 
in science, and deride the ignorance of their predecessors, regardless 
of the old proverb — "Everything has its day." Whenever, there- 
fore, the periodic constitution undergoes an alteration, they either 
obstinately uphold their usual plan of treatment to the manifest 
injury of their patients, or else blindly embrace some system, to 
them new, but which really rests upon ancient and established 
principles. In general, they do not fail to make use of so much 
exaggeration in support of their opinions, and thus succeed in mis- 
leading so many, that none but very well informed physicians can 
distinguish the fallacy of their arguments. 

The medical history of Great Britain affords many striking 
proofs of the truth of these assertions, and is replete with examples 
of the singular obstinacy with which the English cling to opinions 
once formed, a circumstance which has materially contributed to 
obstruct their attaining to general views and impartial conclusions. 
Even to this day, a warm contest is carried on (less, however, in 
books than in the debates of learned societies) between the senior 
and the junior parts of the profession, the former still inclining lo 
Brunonianism, while the latter attribute nearly all diseases to 
inflammation. Both, indeed, appeal to experience to prove the 
justice of their principles, and seem entirely to forget that while 
the propriety of their practice, as applied to particular cases, 



214 GRAVES'S CLINICAL LECTURES. 

remains unimpeached, the very nature of the disease themselves 
may have been changed. A summary review of the character 
assumed by diseases during the last twenty years, both in England 
and other countries, will perhaps afford a solution of this question. 
About the end of the last, and during the three or four first years 
of the present century, the proportion of nervous fevers to other 
diseases was as one to eighteen in Plymouth (Woolcombe), as one 
to sixteen in London (Willan, as one to ten in Newcastle (Clarke), 
and in Liverpool, one to five (Curry). Nor was this scourge of 
mankind less severely felt upon the continent, where typhus, and 
disease^s closely alhed to it, committed extensive devastations, par- 
ticularly (luring the epidemics of Erlangen, Jena, Kiel, Ratisbon, 
and Vienna. Cadiz and Seville were at the same period depopu- 
lated by the yellow fever, and Europe in general suffered much 
from repeated visitations of influenza. An inclination to a sudden 
sinking of the vital power, unpreceded by violent reaction, and 
unaccompanied by any marked symptoms of a gastric or inflamma- 
tory nature, constituted at that period the characteristic form of 
acute diseases, which were always preceded and attended by an 
unaccountable degree of debility. Stimulating and tonic medicines 
obtained, therefore, much celebrity, and every physician who prac- 
tised during that period, attests the injurious or even fatal effects 
which were produced by the use of venesection, and other deple- 
tory remedies. What is still more remarkable, an epidemic typhoid 
pneumonia prevailed in many parts of Germany during the years 
1800-1-2, in which the speedy production of an inflammatory 
state, by means of bark and ether, was the only method which 
afforded a chance of recovery. These facts must impress every 
impartial mind with the conviction, that the constitution of diseases 
has undergone much alteration since that period, and explain why 
physicians did not then employ copious venesection, but were 
obliged to content themselves with ordinary cold effusions, acids, 
and mercury. 

The reign of typhus appears to have ceased with the influenza of 
1804, when a new constitution began, at first more remarkable for 
the disappearance of nervous fevers and other contagious diseases, 
than for any peculiar character of its own. Catarrhal and rheu- 
matic complaints, partly attributable to the weather, prevailed for 
some time, and fevers of an intermittent type became more frequent, 
forming an evident -transition from the purely typhus constitution 
to that of the vascular excitement of the following years. Some 
remnant of the typhus constitution was indeed still perceptible in the 
pectoral complaints which prevailed in London during the winter 
of 1804-5, and were attended with remarkable debility, requiring 
the greatest prudence in the use of the lancet. Venesection was 
indeed often entirely contraindicated, and Bateman states that it 
somtimes even proved fatal. The constitution, however, soon de- 
veloped itself more decidedly, became more universally diffused, 
and obliged physicians to relinquish their former plan of treatment 



GASTRIC CONSTITUTION. 215 

and adopt other measures. Derangement of the alimentary canal 
became its prominent feature in the summer and autumn of 1804, 
and diarrhosa, terminating in dysentery, was often met with. 

This constitution suffered indeed a check from the cold of 1805, 
but it increased again during the following years, and afterwards 
became still more prevalent, manifesting itself by headache, a bitter 
taste in the mouth, a loaded yellow tongue, irregularity of the 
bowels, nausea, and anorexia. The utility of purgatives now be- 
came so obvious, that Hamilton's doctrines soon obtained as much 
celebrity as had been before enjoyed by the stimulating system. 
The nervous fever at Nottingham in 1807, the dysentery at Lon- 
don in 1808, the scarlatina in Edinburgh in 1805, and the measles 
at the same place in 1808, all required the purgative plan of treat- 
ment, and calomel became the favourite cathartic. The advantage 
then derived from the use of purgative medicines is abundantly 
testified by the writers of that period. This gastric constitution 
appeared also on the continent, but its progress was less rapid there 
than in England, where the inhabitants live in a manner calculated 
to augment or even to produce a tendency to gastric diseases. 
There were likewise other circumstances which impeded the for- 
mation of this constitution on the continent. Thus in Germany,, 
the purely nervous constitution had scarcely yielded to catarrhal 
and rheumatic affections, when it was again revived in that un- 
happy country by the political occurrences of 1805-6-7. Typhus 
seldom, however, assumed the character of exquisite, for the rheu- 
matic and catarrhal affections with which it was mixed partook 
somewhat of a gastric nature, as was proved by the great benefit 
derived from the exhibition of emetics and calomel. This appears 
in accordance with the fact that the gastric constitution was more 
fully developed wherever the ravages of war had not extended, 
although it still required less attention in the treatment than the 
rheumatic symptoms, then likewise prevalent. Thus the agues 
which were common at Tubingen about the end of 1806, com- 
menced in general with pain in the belly, vomiting, and irregularity 
of the bowels ; a yellow furred tongue, headache, and tremors of 
the parotids, were of frequent occurrence, and in general gastric 
symptoms were by no means rare. These symptoms gradually 
gained ground, and the reputation of ipecacuanha and cathartics 
increased in the same proportion. At Ratisbon the constitution 
was remarkably gastric in the autumn of 1809, and a nervous fever 
prevailed at Weimar in 1809-10, which was accompanied by bitter 
taste in the mouth, diarrhoea, nausea, and vertigo. Active catharsis 
was injurious in this epidemic, but much benefit resulted from the 
exhibition of castor oil. The advantage derived about the same 
time in Berlin from the treatment of fevers by emetics and cooling 
purgatives, proved that they were there also complicated with gas- 
tric derangements. 

The gastric constitution had scarcely established itself, or become 
pretty generally diffused, when a new character, viz., theinflam- 



216 GRAVES'S CLINICAL LECTURES. 

matory, appeared upon the stage, and has ever since continued, 
sometimes combining itself with the gastric to form diseases of a 
mixed character, such as erysipelas, and sometimes, when favoured 
by the seasons or local circumstances, raising itself to the rank of 
the chief performer. With its appearance, venesection, which had 
previously fallen into disrepute, became once more a favourite 
remedy, and in the course of a few years was pushed so far, par- 
ticularly in Great Britain, that Sangrado's maxim, " C'est une 
erreur de penser que le sang soit necessairea la conservation de la 
vie, on ne pent trop saigner un malade," seems to have been the 
general rule of practice. The same inflammatory constitution be- 
came also general in Germany, but there it neither attained such a 
height, nor required such active treatment as in Great Britain, 
where many circumstances favoured its more perfect development ; 
with us it generally yielded to the use of acids, cold a4Dplications 
of mercury, but in England it called for copious bloodletting. Even 
in 1810, diseases had become more inflammatory at Tubingen than 
they had been previously; but the change was still more perceptible 
in 1813, when the antiphlogistic treatment required the aid of small 
venesections, and nervous fevers were accompanied both by inflam- 
mation and derangement of the digestive organs. Erysipelatous 
affections were also frequent, and in many cases were of a marked 
inflammatory character. Erysipelas and true inflamtnatory fever, 
requiring the use of the lancet, were common at Ratisbon in 1811 ; 
Parrot exhibited acids, especially the acetous, with great success in 
the epidemic nervous fever, which raged at Dorpat in 1812, and a 
diarrhoea of a biHous infiammator}^ nature prevailed at Konigsberg 
during the same year. This important change in the constitution 
became very evident in the nervous fever at Berlin in 1813, as well 
as in the formidable epidemic described by Hufeland, which ensued 
after the war, and raged in the north of Germany during that and 
the preceding year. Although but a few years before the strongest 
stimulants had been necessary to obviate the paralysis which super- 
vened even in the beginning of the disease, yet an opposite practice 
was now required, and antiphlogistic remedies were alone found 
capable of preventing the vascular excitement from terminating in 
inflammation of either the head or chest. In short, the inflamma- 
tory constitution has been prevalent in Germany ever since the 
years 1810-11, sometimes in its pure and marked form, and some- 
times complicated with gastric and rheumatic symptoms. 

This constitution became general at the very same period in 
Great Britain. Dr. Clutterbuck, of London, had indeed ascribed 
the origin of fever to inflammation of the brain, so early as 1807, 
and about the same time Dr. Steiglitz, of Hanover, had recom- 
mended the antiphlogistic treatment of scarlet fever, in preference 
to the stimulating plan then in vogue. But as the inflammatory 
was then still subordinate to the rhuematic and gastric constitutions, 
their opinions did not gain many converts. But the inflammatory 
constitution had increased so much in the autumn of 1809, and 



NERVOUS FEVER. 217 

the winter of 1810, that even Dr. Bateman was obliged to prescribe 
venesection in fevers, a practice quite at variance with his former 
views. Erysipelatous inflammation became common in London, 
Aberdeen, and Leeds, and numerous cases of puerperal fever oc- 
curred in the latter towns, which, according to Gordon and Hey, 
never terminated favourably, except when bleeding and purgatives 
were employed with freedom. But it was not until 1813, when 
the inflammatory constitution had fully developed itself, and the 
bad consequences arising from violent determination of blood to 
the head in nervous fever could not be averted except by decisive 
measures, that venesection came into general use in Great Britain 
in consequence of a publication by Dr. Mills, who had prescribed 
it with much success since 1810. In the same year that truly 
estimable physician. Dr. Thompson, published his admirable work 
upon inflammation. Blackall recommended bloodletting in several 
species of dropsy, and Armstrong employed the same remedy, 
combined with large doses of calomel, in the inflammatory puerperal 
fever which was prevalent at Sunderland. Venesection became 
from this time as great a favourite as ever in England, not, how- 
ever, to the exclusion of purgatives, which were indicated by the 
derangement of the stomach and bowels that accompanied the in- 
flammatory constitution. Both these remedies were found extremely 
beneficial in the nervous fever which was epidemic in Ireland in 
1813-14 ; its inflammatory character being clearly evinced by a 
hard and full pulse during its first stage, and a violent determina- 
tion of blood to the head, by which the headache and raving are 
increased, while its gastric type was not less strongly marked by 
tenderness of the epigastrium, costiveness, or else frequent and 
unnatural alvine discharges, together with a loaded tongue and 
bilious vomiting. The latter symptoms were, in Dr. Grattan's 
opinion, of such importance, that he gave a decided preference to 
the purgative plan. The fever, which had previously been confined 
to Ireland, became generally diflfijsed over the rest of Great Britain 
after the famine of 1816, and continued without intermission for 
four years. Its inflammatory character being peculiarly favoured, 
both in England and Scotland, by the habits of the inhabitants and 
the situation of these countries, venesection attained an unexampled 
degree of celebrity, notwithstanding the representations of the Irish 
physicians, who used that remedy with more moderation. It was 
soon believed that there is. literally speaking, no disease whatever 
in which the lancet ought not to be used, and as the human mind 
is ever prone to extremes, it was soon generally considered, both in 
England and Scotland, to be a well founded pathological inference, 
" there is but one species of fever, viz., the inflammatory, and con- 
sequently venesection is the only true anti-febrile remedy. Such is 
the case in England at present, and it must have been so always, 
and in every part of the world." I flatter myself, however, that the 
preceding observations and statements of facts, drawnfrom authentic 
sources, sufficiently negative these assertions, and estabUsh the real 

19 



218 GRAVES'S CLINICAL LECTURES. 

existence of a change in the constitution of diseases, notwithstanding 
what Dr. Duncan once said to me, " that such changes existed only 
in the imagination of physicians." 

It is now twelve years since Dr: Autenrieth, in his account of 
the State of Medicine in Great Britain, made the foregoing inte- 
resting observations ; and to me it appears that the history of the 
diseases which have since prevailed affords convincing proofs that 
the then injiammatory constitution has again subsided, and is now 
replaced by a typhous type : indeed, it cannot be denied that a very 
great difference exists not only between the present and the former 
scarlatina, but also between the fever of the present day and that 
which prevailed shortly before Dr. Autenrieth pubhshed. But this 
is too important a question for us to decide, without more reflection 
and thought than I have been able to bestow on it, and without 
more facts than I have been able to collect. The opinion I have 
brought forward I do not wish to be received as established ; I look 
upon it as probably well founded, but as yet not proved, except so 
far as to merit further consideration and excite further discussion. 

Indeed, I have for the present been obliged, by the pressure of 
other engagements, to postpone a more accurate examination of 
this subject, and a more severe scrutiny of the facts which just now 
crowd into my memory ; but I conclude with remarking, that the 
wide-spreading epidemic influenza which lately visited the whole 
of Europe, including the British Isles, was not only truly remark- 
able, both for the violence of the feverish symptoms and of the local 
congestions of the chest and heart which accompanied its attack, 
but likewise for the unexpected relation which it was found to bear 
to all measures of active depletion. I appeal to the profession for 
their testimony on this matter — I ask whether all our preconceived 
opinions as to the h priori indications for venesection, leeching, and 
purging, were not found to be contradicted by the effects of these 
remedies in the epidemic influenza of 1833. The sudden manner 
in which the disease came on, the great heat of skin, acceleration 
of the pulse, and the intolerable violence of the headache — together 
with the oppression of the chest, cough, and wheezing — all en- 
couraged us to the employment of the most active modes of deple- 
tion, and yet the result was but little answerable to our expectations, 
for these means were found to induce an awful prostration of 
strength, with little or no alleviation of the symptoms. In some 
who were thus treated, recovery was protracted and doubtful, and 
the strength was not restored for several months. Indeed, nothing 
was more curious than the length of time which was necessary for 
some persons, in order to recruit their strength after an attack of 
this influenza, although that attack had not continued more than a 
few days, and had been judiciously treated, without bloodletting or 
unnecessarily debilitating remedies. I have known some who lapsed 
into a cachectic state of long continued debility from which they 
never recovered ; for, while thus reduced, they fell victims to the 
first acute complaint which seized them. The influenza above 



SCARLATINA. 219 

referred to fully confirmed the opinion I had long entertained, that 
in acute diseases debility and exhaustion of the vital power are by 
no means in every case either caused by, or proportioned to, a state 
of previous excitement. This opinion received further support from 
the symptoms and phenomena exhibited by the Asiatic cholera, in 
which the stage of debility and collapse commenced, and too often 
closed, the scene. Why do I dwell upon these occurrences, and 
why have I so frequently referred to the opinion above expressed? 
Simply because the prevalence of the contrary opinion laid the 
foundation for the injudicious and exclusive application of the lancet, 
and of the antiphlogistic method generally, in Britain, and was, 
consequently, the cause of working excessive mischief. But I must 
have done, and must defer the special pathology of the scarlatina, 
lately epidemic, to our next meeting. 



LECTURE XIX. 

I HAVE already mentioned that the disease called scarlet fever 
assumed a very benign type in Dublin soon after the year 1840, 
and continued to be seldom attended with danger until the year 
1831, when we began to perceive a notable alteration in its cha- 
racter, aud remarked that the usual undisguised and inflammatory 
nature of the attack was replaced by a concealed and insidious 
form of fever, attended with great debility. We now began occa- 
sionally to hear of cases which proved unexpectedly fatal, and of 
families in which several children were carried off; still it was not 
until the year 1834 that the disease spread far and wide, assuming 
the form of a destructive epidemic. The nature of the disease did 
not appear in the least connected with the situation or aspect of 
the patient's dwelling, for we observed it equally malignant in 
Rathmines as in Dublin, on the most elevated habitations on 
mountains as in the valley of the LifFey. It raged with similar 
violence at King's Town, and throughout the provinces, exhibit- 
ing, so far as I have been able to learn from country practitioners, 
the same type over the whole of Ireland. The state of the weather 
seemed to exercise no influence either upon its diffusion or its 
symptoms, which continued to exhibit equal virulence, no matter 
whether it was wet or dry, warm or cold, calm or stormy. The 
contagion seemed to act as a more deadly poison on the individuals 
of some families than upon those of others, and, consequently, 
when one member of a family had died, there was always much 
reason to fear for the others when attacked. At first I thought that 
its greater severity in such cases could be traced to a strumous 
habit, but subsequent experience did not confirm this suspicion, 
for the most scrofulous family I ever saw went through the dis- 



220 GRAVES'S CLINICAL LECTURES. 

ease without a death, whereas in some others the mortality was 
great, although not a single indication of a strumous diathesis could 
be detected. Many parents lost three of their children, some four, 
and in one instance which came to my knowledge, five very fine 
children were carried ofl^. As usual in such epidemics, the degree 
of intensity with which different persons were attacked varied ex- 
ceedingly, some exhibiting the mildest form of scarlatina simplex, 
which required no treatment, and scarcely confinement to the room, 
while the majority were severely affected. When the disease was 
violent, it assumed one or other of the following forms: — 

First — It at once produced not merely fever with sore throat 
and headache, but such violent congestion of the brain, and deter- 
mination to the head, as occasioned convulsions and apoplectic 
coma on the first or second day. This happened to a fine young 
woman of robust habit in Worhurgh street, to whom I was called 
by my friend Dr. Brouton. She was attacked with convulsions 
on the second day, and died comatose on the third. In her the 
scarlet eruption was extremely vivid and general, a fact I notice as 
a proof that the congestion of internal organs was not caused by 
any retrocession of the eruption. In truth, as will appear hereafter, 
the worst cases had the most general and most intense cutaneous 
efflorescence. When this tendency to the head took place in so 
violent a manner at the very onset, the patient was seldom saved; 
sometimes, however, very active measures of depletion, general and 
local, relieved the brain, and the case then went on favourably. 
This happened in a young gentleman residing in upper Baggot 
street, to whom I was called by the late Mr. Nugent, of Merrion row. 
When the scarlet fever attacked a person subject to epileptic fits, 
the tendency to the head was increased by the epileptic habits, and 
the fits of convulsions at once supervened. Thus in the case of 
a gentleman, aged twenty-two, who had been for several months 
treated by Mr. Colles and me for epilepsy, the fits commenced on 
the second day of scarlatina, and continued with frightful violence 
until the fifth day. when they proved fatal. In a young lady resid- 
ing near Black Rock, to whom I was called by Dr. Wilson, pre- 
cisely the same thing occurred. She had been subject to epilepsy 
for many years, and when the scarlet fever commenced she was 
at once siezed with frequently recurring fits, which, in spite of the 
most active measures, ended in fatal coma on the fifth day. 

In the second form of the disease which I noticed, the symptoms 
were exceedingly violent and intense from the beginning, and the 
disease set in with the usual symptoms of severe exanthematous 
pyrexia, remarkable in the very commencement for the violence of 
the accompanying headache and spinal pains, and for the great 
irritability of the stomach and bowels. Indeed one oi the very first 
svmptoms in such persons was nausea, vomiting, and bowel com- 
plaint. Large quantities of recently secreted bile were thrown up, 
and the patient passed frequent, at first semifluid and afterwards 
fluid stools, curdled green or safli'ron yellow, and evidently composed 



SCARLATINA. 221 

of bile suddenly effused into the intestinal canal, with a copious 
and hurried secretion of mucus from the internal membrane of 
the bowels, and mixed with some true fecal matter. It was sur- 
prising what quantities were thus thrown up, and passed from the 
bowels by some during the first day or two of the disorder ; neither 
the constant repetition of the nausea and vomiting, nor the abund- 
ance of the discharge from the stomach and bowels, in the slightest 
degree mitigated either the violence of the fever or of the headache, 
or seemed to prevent the full formation of the eruption. It was 
curious to observe that this obstinate vomiting and purging was 
unaccompanied by the slightest epigastric or abdominal tenderness ; 
during its continuance the belly became fallen and soft. In fact its 
cause was situated not in the belly, but in the brain, a fact I did not 
perceive until I had had an opportunity of vi'atching the progress of 
five or six such cases. It depended on cerebral irritation and con- 
gestion, and was in nature very similar to the irritability of stomach 
and bowels which so often accompany, and too frequently mask 
the progress of, acute hydrocephalus. As soon as I had become 
aware of the pathological relations of this vomiting and piirging, I 
did not confine my endeavours to check these symptoms to mea- 
sures intended to act directly on the stomach and bowels, such as 
effervescing draughts, chalk mixture, stupes, leeches to the epigas- 
trium, &c., &c., I changed my plan of treatment, and turned my 
attention to the state of the cerebral circulation. Having in a 
former lecture referred to this topic, and having explained to you 
the manner in which derangement of the stomach and bowels of a 
properly gastric origin is to be distinguished from disorder of the 
digestive apparatus, originating in a sympathetic derangement of 
function, itself caused by a morbid condition of the brain, and hav- 
ing already pointed out the importance in practice of not confound- 
ing these two states, one or other of which is so common in the 
commencement of violent fevers, phlegmasia, and exanthemata, I 
shall not at present dwell any longer on this subject. The second 
form of scarlatina was likewise remarkable for the violent excitation 
manifested from the very beginning in the circulating system and 
in the production of animal heat. The pulse at once rose to above 
100, it w^as seldom less than 120, and in many cases, particularly 
in young people, it ranged from 140 to 150. I have never in any 
other disease witnessed so many cases of excessively rapid pulse. 
In general the pulse in this form was regular, but in two cases it 
became irregular ; one was that of a gentleman living in Upper 
Mount street, whom I attended along with Dr. Marsh ; his pulse 
became intermitting and irregular on the third day, and continued 
to be more or less thus affected for about a week. This gentleman 
was attacked with subsultus, delirium, jactitation, and various nerv- 
ous symptoms, at a very early period, and coniplained constantly 
of his throat and head. The former was violently inflamed, and 
his skin was covered with a bright-red eruption. On the ninth day 
iiQ was seized with convulsive fits of great violence, and which 

19* 



222 GKAVES'S CLIMCAL LECTURES. 

returned very frequently during the night; his case appeared 
^ uiterly hopeless, and yet he perfectly recovered. In a young lady, 
whose case is detailed by Dr. Kolan, great irregularity and inter- 
missioD of the pulse Gommenced about the eighth day, and con- 
tioued during the state of danger; she also recovered. Of course 
irregularity of the pulse was in niany not so much a symptom of 
disease as of approaching death, but then the state of the patient 
could not be mistaken, judging from all the other circumstances of 
the case. The acceleration of the pulse abated in all when an evi- 
dent improvement in the general condition took place, but in few 
did the pulse become quite natural for many days after a favour- 
able change, and in none did it fall to its usual standard in the 
course of twelve or twenty-four hours, as it not unfrequently does 
a f -.'/.-^ crisis of continued fevers; in fact, the scarlatina never 
e T .h a well-defined crisis. As to the temperature of the 

b:_ i ?.ve already observed that in the cases I am now describ- 
iiig .: was from the first considerable, and continued elevated until 
a very short period before death. Both the pulse and the heat of 
skin, however, were very easily reduced in energy by the use of 
the lancet or by the repeated application of leeches, and it was not 
uncommon to observe that even the judicious use of these means 
induced a general coldness of surface, very great sinking of the 
strength, and a faltering state of the pulse. This was remarkably 
the case in a young lady whom I attended along with Mr. Wilkin- 
son, in Black Rock, and also in one of the family whose cases are 
related by Dr. Nolan. In both, these effects were very obstinate and 
alarming, for reaction was not restored uruil after the lapse of more 
than twelve hours ; both finally recovered. The pulse was sharp 
but not strong, and resembled the pulse of great irritation rather 
than that of true inflammation. The most distressing symptom 
at tlie commencement of this form of scarlatina was the sore 
throat ; the fauces were violently inflamed, and deglutition conse- 
quently much impaired, while a general soreness was felt in th< 
back of the head and neck ; urgent headache was complained of byl 
all, and from the second day the eyes became suffused; great rest- 
lessness, anxiety, jactitation, moaning, and interrupted raving scoi 
made their appearance, and in many sleep was banished or utterli 
broken by startings and delirium before three or four days hai 
elapsed. The eruption had now arrived at its height, which it di< 
with great rapidity, dating from the first moment of its appearance, 
so that the skin, everywhere covered with a scarlet eruption, 
resembled in appearance the hue of a boiled lobster. In the: 
violent cases the efflorescence was perfectly continuous, and nevei 
broken into spots or patches ; the skin appeared as if evenly dye« 
with one uniform colour; the surface of the tongue was likewis 
much afiected with the same exanthematous redness, and sooi 
became foul, and afterwards dry and parched. The sudden dry in 
of the tongue on the fifth or sixth day indicated in this form a rapid] 
aggravation of the disease, and death in several cases was observe*" 



SCARLATINA. 223 

to follow this change in less than twenty-four hours, when this 
change was, as in a young gentleman Mr. Rumley and I attended 
in French street, accompanied by a sudden acceleration of the pulse 
and increase of the jactitation and delirium. In this form the brain 
and nervous system seemed to be the parts which suffered most, 
and many became insensible for several hours before death ; others 
had convulsions; when the patient survived the seventh day there 
was a fair chance of recovery, but nrvany, too many, died on the 
fourth, fifth, or sixth days. 

After I had witnessed a few examples of this form of scarlatina, 
I consulted with several of my friends and colleagues, and we 
determined to use- the most active measures of depletion in the very 
first instance that occurred ta us. A case was not long wanting. 
Dr. Marsh and I were engaged in prescribing for some children 
labouring under the epidemic, in a house- in^ Pembroke street, where 
our attention was directed to a fine boy, six years old, and hitherto 
perfectly healthy, who was, while we were paying our visit, 
attacked with the first symptoms of the complaint; we immediately 
resolved that as soon as the stage of rigour and collapse which 
preceded the febrile action had passed, to visit him again and act 
energetically, if circumstances seemed to permit it. Accordingly we 
came again in the course of a few hours, and found reaction already 
established, attended with vomiting, purging, and headache. The 
sore throat, too, was much complained of, and there was great ten- 
derness of the external fauces. We ordered relays of leeches, eight 
at a time, to the neck, for the purpose of relieving both the throat 
and brain, and we administered James's powder and calomel inter- 
nally. On the next day the skin was burning in spite of a copious 
loss of blood from the leech-bites, the eruption vivid and already- 
established, the pulse 140, and there bad been little or no sleep. 
Relays of leeches were again ordered, and persevered in until con- 
siderable and lasting faintness was produced, and yet no impression 
seemed to be thereby made on the disease ; no abatement of its 
virulence seemed to be the result, for the raving became more in- 
cessant on the second night, and on the third day suflfusion of the 
eye commenced, and the tongue became parched. Shaving of the 
head, the most industrious application of cold to the scalp, and va- 
rious other remedies were in vain applied ; the pulse became weaker, 
the breathing quicker, the strength failed rapidly, raving and de- 
lirium gave place to insensibility and subsultus, and the patient 
died on the fifth day. In this case depletion was applied at once 
and most decidedly, for we blanched and weakened the boy by loss 
of blood as far as it was possible to venture, and yet the disease 
was not in the least degree checked, nor the symptoms even 
mitigated. 

A fine boy, thirteen years of age, was attacked in the county of 
Wicklow, when he was placed under the care of a very judicious 
practitioner, who did not use either venesection or leeches, but re- 
lied chiefly on the exhibition of diaphoretics, particularly antimo- 



224 GRAVES'S CLINICAL LECTURES. 

nials. The boy died on the seventh day, having suffered much 
from delirium, subsuitus, want of sleep, &c. His brother, who was 
one year older, and a very strong boy, was seized with the disease 
in Dublin, and placed immediately under my care. I had the ad- 
vantage of Mr. Rumley's assistance, and we determined to prevent 
the supervention of the cerebral symptoms if it were possible to 
do it by means of antiphlogistic treatment; we failed, and our 
patient died on the sixth day. In short, this form of the disease, 
where the pulse, without becoming strong, at once became extremely 
rajjid, bore venesection badly, and required great caution even in 
the application of leeches; the nervous symptoms only appeared 
accelerated by the system of depletion, although the heat of the 
skin suggested its employment. The derangement of the brain and 
nerves in this form depended on something more than the violence 
of the circulation, and originated in something altogether different 
from mere cerebral inflammation or congestion. What that some- 
thing was I cannot even conjecture, but it was probably the result 
of an intense poisoning of the system by the animal miasma of the 
scarlet fever. Every tissue of the body seemed, if I may use the 
expression, equally sick, equally overwhelmed, and it is probable 
that the capillary circulation in every organ was simultaneously 
deranged. It was not gangrene of the throat which proved fatal, 
for in>this form it never occurred ; it was not inflammation of any 
internal viscus, for such was not found on post-mortem examination 
of the fatal cases, but it was a general disease of every part. In 
many, another state of things, which required to be carefully dis- 
tinguished from that just described, existed, and the disease was 
evidently attended with an inflammatory state of the constitution, 
requiring energetic measures. In such cases the symptoms were 
severe in the commencement, the throat very sore, the efflorescence, 
however, not quite so sudden or so perfect, and the pulse never 
near so quick, never excessively rapid, and always strong and dis- 
tinct. Such bore bleeding and leeching well, and experienced from 
their use almost immediate alleviation of the sore throat, headache, 
and restlessness, and were not much weakened by the depletion. 
It must be confessed that it was often exceedingly diflicult to deter- 
mine, d priori, whether the depletory system ought or ought not to 
be tried ; where doubt existed, my custom was to try moderate 
leeching, and from its effects I judged of the propriety of per- 
severing. 

The disease very frequently occurred in a third form, more sin- 
gular still than the two first, and much more insidious in its com- 
mencement. This form was evidently very common in the epide- 
mic scarlet fever described by Withering, as cited by Dr. Tweedie. 
In this form the disease was ushered in by the usual symptoms of 
pyrexia, together with sore throat, slight headache, and in due time 
a very moderate and normal eruption. The symptoms continued 
moderate, the patients, after the first few days, slept tolerably well 
during the night, had no raving, and were quiet during the day. 



SCARLATINA. 225 

About the fourth or fifth day all the febrile symptoms had so far 
subsided, that a most accurate examination could detect nothing 
urgent, nothing in the slightest degree either alarming or calculated 
to excite the least anxiety in the patient's condition. His skin be- 
came nearly of the natural standard, his thirst diminished, and the 
pulse was now scarcely accelerated ; a calm nearly complete, in 
fact, seemed to have followed the first onset of the disease; and 
on entering the room the physician might easily be deceived, as I 
myself was more than once, into the pleasing hope that all danger 
was past, and that perfect recovery might confidently be anticipated. 
This hope was, in truth, founded on such circumstances as we can 
usually rely on ; for who would prognosticate danger where his 
little patient, sitting up in bed, and perhaps eating a dry crust with 
some appetite, had a placid countenance, and had enjoyed a night 
of tranquil sleep ? Regular alvine evacuations, diminution of thirst, 
sore throat, headache, and fever, together with the normal state 
of the cutaneous eruption, all conspired to confirm a favourable 
prognosis ; and so matters proceeded, the family dismissing all ap- 
prehension as to the result, and the physician most probably discon- 
tinuing his attendance about the seventh day, in the belief that all 
danger was over, and that his interference was no longer necessary.. 
Matters proceeded thus until the eighth or ninth day, when a cer- 
tain degree of restlessness was observed to occur, and in the mo-m- 
ing a slight return of fever might be noticed. Then it was that a 
peculiar train of symptoms set in. The nostrils assumed a sore 
and irritated appearance about the edge of the alse, and a serous 
moisture began to flow from their internal cavities. Sore throat 
was again complained of, the skin became hot, great debility and 
prostration of strength came on suddenly, a painful tumefaction 
commenced in the region of the parotids and submaxillary glands. 
This tumefaction increased rapidly, becoming every day harder, 
more elevated, diflTused, and exceedingly tender, but without much 
redness. In the course of a few days it surrounded the neck like a 
collar, and being attended with swelling of the face, the poor little 
patient's countenance was sadly disfigured. In the mean time the 
discharge from the nose had increased considerably, and become 
more viscid -and fetid; the internal membrane lining the nasal 
passages was afl^ected throughout, its entire surface everywhere 
inflamed and tumefied, so that a snaffling sound was produced 
when the patient breathed through his nose; at length the dis- 
charge increased to such a degree, that the nostrils became com- 
pletely impervious to the air in breathing. The state of the throat 
generally began to alter for the worse at the very commencement 
of this change; and a similar inflammation, attended with an ill- 
conditioned secretion of lymph and fluid, occupied the entire sur- 
face of the mouth and tongue, and at last spread deep into the 
pharynx. While this was going on, the fever freshly lit up at once 
exhibited the most decided symptoms of the worst form of typhus 
and subsultus, constant muttering, raving, anxiety, want of sleep, 



226 GRAVES'S CLINICAL LECTURES. 

restlessness, moaning mingled with an occasional screech, remind- 
ing one of that which is so ominous in hydrocephalus. Great 
difficulty was now experienced in swallowing, and the drink was 
frequently spurted out of the mouth after a vain attempt at degluti- 
tion. Matters now proceeded rapidly from bad to worse, and at 
last, after much suffering, death closed the scene, being preceded 
for many hours by a state of extreme restlessness, during which it 
was impossible to determine whether the patient was still sensible. 
The swelling of the neck went on increasing to the last, but seldom 
exhibited any tendency to point ; it continued, on the contrary, 
everywhere hard, or, at most, became indistinctly softened, or, to 
use a technical phrase, " boggy." When cut into, no matter was 
found ; blood, serum, and a diffijsed cellular slough, not separated 
from the living tissues, were observed on making the incision. 

I shall conclude these remarks on scarlatina, by reading you a 
letter I received on the subject from Mr. Ferrall. His observations 
are extremely valuable, more especially those which are made 
towards the termination of the letter, where he describes a most 
important sequela of scarlatina not hitherto mentioned by any 
writer. 

" My Dear Sir, — In reply to your letter, I have the pleasure to^ 
send you a few brief notes of my experience of the scarlatina of last 
autumn and winter. 

*' Of seventeen cases of which I possess notes, four occurred ii 
adults, three in children under four years of age, and the remainder) 
at different ages between the latter and fourteen or fifteen years. 
I seldom saw the cases in the commencement. The mode of 
attack was occasionally similar to that of common sore throat, fol- 
lowed by rigors. Sometimes violent pyrexia and shiverings, with 
intolerable headache, and even delirium, preceded by other signs. 
I^ some few cases, the efflorescence first attracted notice, the fever 
in these instances being throughout so mild as scarcely to demanc 
attention. 

" The progress of the disease was various, but usually bore 
relation to the character of the incipent fever. In general, th( 
fever increased in intensity as the disease advanced, or as ne^ 
parts became engaged, but this was not always the case. In tw( 
instances which 1 saw in a state of great vital depression on th« 
third or fourth day, I was assured that the early fever was very 
high, although it had passed rapidly into the typhoid state. 

"The danger sometimes appeared to arise from the condition of 
the entire system, sometimes from that of important parts. Of two 
cases which I saw when dying, one was sinking like a person in 
typhus fever ; the other, a boy thirteen years old, was moribund in 
the coma, which succeeded to violent phrenitic delirium. The 
latter case was remarkable in this, that the phrenitic state occurred 
while the eruption was in its prime, the whole body retaining its 
deep scarlet colour until a short time before his death. The dis- 



SCARLATINA. 227 

ease in this instance set in with delirium, which had been sub- 
dued, I have reason to believe, by the most active means. Death 
occurred in one instance from croup, the disease of the throat 
having passed into the trachea and bronchial tubes. In another, 
sloughing of the fauces, with low fever, carried off the patient on 
the sixth day. 

" In several, who ultimately recovered, life was seriously endan- 
gered by local inflammatory attacks. In one instance, a girl about 
seven years old, enteritic symptoms sprang up suddenly while the 
patient was in a very weak state, and were with difficulty subdued. 
In another, a boy ten years old, acute pain in the region of the 
heart occurred when the eruption was on the decline ; it was 
accompanied by short cough, palpitations, dyspnoea, rapid though 
not irregular, pulse, and sudden accession of fever. There was no 
iperceptib]e frotteme?it, but the action of the heart was violent, and 
there was acute pain on pressure. It yielded to leeching, followed 
by calomel, with James's powder, till the gums were slightly 
touched. 

" Another patient, a girl twelve year^ old, narrowly escaped the 
effects of sloughing of the throat. Croup occurred in two in- 
stances, in which, notwithstanding the opinions of M. Trousseau, I 
could not doubt its origin in scarlatina. It happened, no doubt, in 
cases which had exhibited the diptheritic patches, without much 
surrounding inflammation on the tonsils, but the eruption was suf- 
ficiently marked to remove all obscurity. One child, who reco- 
vered, ejected the false membrane (which I still preserve) in a 
tubular form, and presenting a cast of the trachea a little beyond 
its bifurcation. In the child before mentioned, who died, patches 
of false membrane were also ejected, but she sank exhausted, and 
the disease was afterwards discovered to have extended far into 
the bronchial ramifications. 

" Although the treatment w^s generally antiphlogistic, this plan 
was not always applicable, even in the commencement of the dis- 
ease. In all instances which I had an opportunity of observing, it 
was necessary to watch the effects of local bleeding. It was easy 
to pass the boundary of relief, and then most difficult to repair the 
loss, and meet the symptoms of exhaustion when they had actually 
set in. Wine and diffusible stimuli were often required from this 
cause alone, even when the cases had nothing of the malignant or 
typhoid character in their nature. 

'* Tepid sponging appeared in many instances preferable to cold, 
and I think the soothing effects were of longer duration. Reaction, 
and the distressing sense of burning heat, did not appear to recur 
so soon as when cold fluids were employed. Purgatives, except of 
the mildest kind, were not well borne, but cooling diuretics were 
clearly indicated, and when persevered in, had, in many cases, the 
apparent effect of anticipating the sequelae of the complaint. 

*' The ulcerations and sloughings of the throat were treated by 
nitrate of silver, alum, and the chlorides, according to their stales. 



228 GRAVES'S CLINICAL LECTUKES. 

But none of these applications were to be depended on, when the 
colour of the fauces was intensely red, unless a few leeches had 
been previously applied. In one gentleman, twenty-eight years of 
age, free leeching, externally, (to the number of forty.) failed in 
removing the sense of suffocation or enabling him to swallow. A 
few leeches applied to the inside of the nostrils was followed by 
copious bleeding and immediate relief. The latter expedient was 
indicated by the tumid state of the velum and pituitary membrane, 
the stertorous breathing, and complete occlusion of the nares. 

" Its mode of spreading in families was uncertain. It sometimes 
attacked children within a few days of each other ; at other times, 
a fortnight has elapsed before I was again requested to see a new 
patienL Some children escaped the disease altogether. 

•' AmoHg the sequelae which I had occasion to see, diarrh^^ea 
occurred m two or three instances, chronic bronchitis in one, and 
anasarca in four. The urine was slightly albuminous in two of 
the latter cases before the face and limbs began to swell : in the 
other two it exhibited this character when the disease was formaed, 
but I did not see them previously. The treatment of the anasarca 
was antiphlogistic and diuretic, and succeeded in restoring three to 
perfect health : the fourth still remains an invalid, but not from this 
cause; the apex of the right lung affords evidence of tubercular 
disease, 

" I have now to mention a peculiar affection of the neck, which 
I have not before seen in connection with scarlatina, but of which 
four cases have occurred during my observation of the epidemic in 
question. 

" Case L — About the beginning of August, 1S34, 1 was requested 
by my frien-d Dr. Davy to see a young girl, ten years old, in Upper 
Baggot street. Her convalescence was tedious, some degree of 
fever still existing at the end of six weeks from the commencement 
of the attack. But her principal complaint was severe pain of the 
right side of the neck, close to the head, and extending as high as 
the vertex on the least motion of the part. She could not raise th< 
head from the pillow without putting a hand at each side for its' 
support, and when taken out of bed, instinctively sought a resting- 
place for the chin. The face was awry, its vertical diameter pass- 
ing from above downwards, and from right to left. Posteriorly 
the upper cervical vertebres were curved, the convexity of the- 
curve being situated a little to the left of the middle hne ; there 
was considerable swelling of the soft parts covering the bones. 
Pressure here was intolerable, and the least attempt to rotate the 
head occasioned severe pain. . Deglutition was now tolerably easy, 
but there had been considerable difficulty of swallowing during the 
early period of the compIainL There was here obviously a curious 
state of the articulation of the atlas and dentata, and we did Bot 
expect to remove the curvature. Perfect rest was, however, en- 
joined, and the usual remedies employed with a view to arrest the 
further progress of the disease. She gradually recovered her 



SCARLATINA. 229 

health, and is now hvely and well grown, but the curvature is per- 
manent. 

"Case II. — Early in August, 1834, Mary Inglesby, of Russell 
Place, set. 7, was sent to me by Mr. Long, of Summer Hill. She 
was confined to bed in scarlatina for a fortnight. At the end of 
this time she was taken out of bed, and then the head was observed 
to be turned to one side. It was now five weeks altogether from 
the beginning of the disease, and the parts were still in the same 
state. The face was awry. She complained of pain in the con- 
cavity of the curve and that side of ihe head, and could not bear 
the slightest motion or shock. Leeches were prescribed, and 
calomel given afterwards in doses of a grain, three times a day, till 
the gums were touched. As soon as this effect was produced, the 
pain subsided, and the head gradually acquired its natural position. 
Her recovery was complete. 

" Case III. — A younger brother of Mary Inglesby was subse- 
quently under the care of Mr. Long for scarlatina. The same state 
of the head and neck were delected on the thirteenth day, and 
treated by Mr. Long on the same plan as that adopted in the former 
case. The pain disappeared as soon as the mouth was made sore, and 
the posiiion of the head became natural. He is now in good health. 

" Case IV. — I met Mr. Edgar, of Arran Quay, in February last, 
in the case of a young gentleman about six years old, whose conva- 
lescence from scarlatina was tedious, and in whom the difficulty of 
swallowing persisted after the redness of the fauces was removed. 
On taking him out of bed, it was remarked that he was quite 
unable to keep the head erect. The symptoms were similar to 
those of the two last cases, but in a milder degree. A few leeches 
were applied, and evaporating lotions instantly used to the part, on 
account of considerable local heat. The leeching was repeated in 
a day or two, but as the symptoms yielded rapidly, and as he had 
some tendency to diarrhoea, calomel was not employed. In about 
a fortnight, the natural position of the head and neck was restored. 
, " I can offer no better explanation of the occurrence of this affec- 
tion, during the progress of scarlatina, than by supposing that the 
inflammation of the fauces, and back of the pharynx, was propa- 
gated to the covering of the spine, and thence more or less deeply 
to the adjoining parts. In all those cases there had been marked 
and prolonged difficulty of deglutition as a symptom of the disease; 
and it is to this circumstance I am desirous of calling attention, as 
affording an index for a careful review of the condition of the 
spine during the period of convalescence. Should a child be 
observed to lie more on one side than the other, and evince an un- 
willingness to be disturbed, it would be an additional reason for 
suspecting a tendency to this complaint. 

" Believe me, dear sir, 
" Yours, very truly, 

Joseph M. Ferrall, 

« Rutland Square^ west, May SOth, 1835.'^ 

20 



230 GRAVES'S CLINICAL LECTURES. 



LECTURE XX. 

I SHALL speak to-day of some prescriptions which I am in the 
habit of using in the treatment of fever. In the treatment of fever 
it is frequently of importance to gain time, and periods will occur 
in every long fever, in w^hich there may be no direct indication for 
the exhibition of any powerful remedy; at the same time, such is 
the ignorance of non-medical persons, and the anxiety of the pa- 
tient's friends is so intense, that they cannot imagine how it is 
possible for an attentive physician to let twelve hours pass away 
without doing something. The mere circumstance of seeing the 
fever going on, is sufficient proof to them of the necessity of making 
renewed efforts for its removal. This, however, is very excusable. 
If any of you happened to be ill, I dare say you could scarcely 
bear to pass many hours without taking something which you 
supposed might prove either immediately or remotely usefal. Con- 
sequently, we could not treat fever in a satisfactory manner without 
medicines of what may be termed an expectant character, and cal- 
culated to fill up the spaces intervening between those periods when 
active treatment is necessary. You are not to suppose that in 
ordering such medicines you are acting a dishonest part, and prac- 
tising a deception unworthy of your profession ; on the contrary, 
your conduct is perfectly just and proper : and though you were 
convinced that no medicine is required, still it will be necessary to 
prescribe something, if you do not wish to lose the confidence of 
the patient and his friends. Again, if at a period when you say 
that no medicine is necessary, and when the patient has passed 
twenty-four hours or two days without taking anything, an unex- 
pected turn in his disorder should take place, people will be very, 
apt to say, either that you did not know what to do, or that y^i 
took no steps to obviate the threatened change, and that one or two^ 
days were completely lost. Conduct like this has frequently brought 
down a great deal of censure on medical men. It maybe said that! 
these are mere prejudices, and above the dignity of a man of firntij 
and consistent character ; but when prejudices are intimately blend- 
ed with human nature, and constitute, as it were, a part of it, it is] 
much better in many cases to submit to them, particularly when} 
compliance does not involve a sacrifice of principle. In cases of 
acute disease of any considerable duration, and especially in private] 
practice, there are periods when medicines of an expectant and] 
temporising character must be employed, and hence the introduc- 
tion of a class of remedies extensively used in fever and other com- 
plaints, and generally denominated palliatives. These are remedies' 
which have a general tendency to assuage thirst, act as diluents, 
gently promote the secretions of the skin, intestinal canal, or kid- 
neys, and which are known to possess at least the negative quality 
of doing no harm. They are most commonly prescribed in com- 



RETENTION OF URINE. 231 

bination with a considerable quantity of fluid, and hence are admin- 
istered either in the form of draught or mixture. The medicine 
in most general use among the physicians of Dublin is one which 
was introduced by Dr. Cheyne. It is prepared by dissolving a 
dram of carbonate of ammonia in three ounces and a half of water, 
with as much lemon juice as will saturate it ; the mixture is then 
sweetened with syrup of orange peel, and given in doses of two 
tablespoonfuls every third or fourth hour. In this way a solution 
of the citrate of ammonia is formed which possesses the properties 
of a mild anti-febrile, and gently stimulant diaphoretic. 

Novi^ it cannot be denied that this mixture answers the purposes 
of an expectant remedy, calculated to pass away the time, and do 
no injury; but it appears to labour under one considerable disad- 
vantage — it is not agreeable to the taste. If you taste the citrate 
or acetate of ammonia, you will find that its flavour is by no means 
pleasant, and I need not tell you that in cases where there is no ac- 
tual indication to be fulfilled, it is of importance to have something 
that will not be disagreeable to the patient. Feeling, therefore, the 
necessity of altering this prescription, I have lately introduced 
another which I am happy to find has been extensively adopted, and 
which is formed by substituting the carbonate of soda for the car- 
bonate of ammonia. The mode in which I generally employ it is 
the following : — Carbonate of soda, a dram ; water, four ounces ; 
lemon juice, a sufficient quantity to saturate the alkali ; a syrup of 
orange peel, half an ounce ; tincture of orange peel, two drams. 
A little more that an ounce of lemon juice will be sufficient to 
saturate this quantity of carbonate of soda, w^hereas it would take 
from two and a half to three ounces to saturate the same quantity 
of carbonate of ammonia. If you wish to have a weaker solution, 
and I believe it is the better way, you can dissolve a dram of car- 
bonate of soda in five ounces of water instead of four. Nothing 
can be more agreeable in flavour than this mixture. The citrate 
of soda which is formed, does not, it is true, exert any active influence 
on the animal economy, but it partakes in the properties of neutral 
salts, determines gently to the kidneys, tends to keep up a soluble 
state of the bowels, and forms a most grateful and refreshing bever- 
age. The syrup of orange peel gives the mixture an extremely 
pleasant flavour, and this is further heightened by the agreeable 
aromatic bitter of the tincture. Since I commenced using it, I have 
found it to answer all the necessary purposes extremely well, and I 
can recommend it to you with confidence. 

I shall now speak of the principles which guided me in pre- 
scribing for a young woman in the chronic ward, named Catharine 
Roach. I am anxious to make a few observations also on her 
case, as it belongs to that anomalous and frequently unmanageable 
class of female complaints, which puzzle the practitioner so much, 
and which he is so often called on to treat. The most prominent 
feature in the case of this young woman, who is of stout make, 
considerable embonpoint, and rather healthy appearance, is reten- 



232 GRAVES'S CLIXIC^L LECTURES. 

tion of urine. Retention of urine occurs much more frequently in 
young and tolerably healthy females than in males at the same 
period of life. It is very rare to meet with retention of urine in 
males under thirty, except in cases of fever, or disease of the 
urinary passages ; in a healthy person, and who is going about in 
the usual way, it is never observed. This, however, is not the 
case with females : young females, apparently in good health, and 
going about as usual, not unfrequenth' suffer from retention of 
urine. 

The history of this girl's case is briefly as follows. About twelve 
months ago she was treated in Mercer's Hospital for fever, during 
which she laboured under retention of urine; this disappeared with 
the return of convalescence, but after some time it again attacked 
her, and has appeared at intervals ever since, being sometimes 
absent for weeks, and sometimes only for a few days. You per- 
ceive, then, it is quite evident from the history of the disease, from 
tlie circumstances of its being unaccompanied by any local inflam- 
mation or change in the part affected, and from its occurring during 
the course of fever in which the brain, spinal marrow, and other 
parts of the nervous system were engaged, that the retention of urine 
must here depend solely on a nervous cause. It is, in fact, a species 
of temporary paralysis of the bladder, arising from the nervous 
int]uence by which the motions of that organ are regulated, being 
subjected to occasional disturbance. This affection of the bladder 
is of frequent occurrence among hysterical females, and is some- 
times met with in persons who appear to have no other disease. It 
is also very apt to continue for a long time; I have seen it last for 
months, and require the daily use of the catheter. 

In this case the origin of the disease did not appear to have any 
connection with the discharge of the uterine functions, the cata- 
menia were regular, and there was nothing connected with the 
state of the uterus on which it could be supposed to depend. But 
on inquiring carel'ully into the historv of her complaint, we found 
that ever since she had laboured under fever, she had experienced 
a train of symptoms indicating that the derangement of the nervous 
system which then occurred had never completely subsided ; she 
complained of pain in the head and loins, want of appetite, con- 
stipation, and tympanitis; symptoms which all indicated that a con- 
siderable degree of nervous derangement still existed — in other 
words, that the affection of the nervous system which accompanied 
her fever had now become, as it were, chronic, and with the chro- 
nicity. had assumed the intermittent character of nervous diseases. 

I shall now explain briefly the mode in which I treated this case, 
and the reasons which induced me to prescribe the remedies em- 
ployed. In the first place, it was necessary to remove and obviate 
constipatioiL My object here was not merely to keep the bowels 
open, but also to give such medicines as would agree with the sto- 
mach and lessen the tendency to tympanitis. Xow if, in addition 
to these purposes, I could accomplish aDother very important object, 



RETENTION OF URINE. 233 

namely, to strengthen the tone of the nervous system, and effect an 
alteration in its mode of action, I considered that I should fulfill all 
the required general indications. I therefore ordered an electuary, 
which I have been much in the habit of using in similar cases, and 
from which I have often derived remarkable advantage. 

R Electuarii sennae,§iij, 

Bitartratis potassac i 

Sulphuris loti >aa5ss. 

Carbonalis ferri 3 

Syrupi zing;iberis, q. s. 
Ut fiat electaarium. Sit dosis cochleare minimum ter quotidie. 

I am sure every gentleman present understands the principles on 
which each ingredient of the foregoing combination was prescribed. 
The electuary of senna, or, as it is usually termed, the lenitive elec- 
tuary, by its mild but extensive operation on the digestive tube, 
forms an excellent basis for a combination like this. The carbonate 
of iron was ordered, because it was obvious that the young woman 
laboured under considerable derangement of the nervous system, 
requiring the salutary influence of a tonic calculated to strengthen 
the nerves, and thus gradually restore them to their healthy and 
normal action. Besides, we know that in cases where persons 
labour under a relaxed and debilitated state of the digestive organs, 
giving rise to tympanitis, constipation, and want of appetite, the 
carbonate of iron, by giving additional vital energy to the intestinal 
tube, tends not only to restore appetite, but also to check tympanitis 
and promote defecation. You perceive, then, what my motives 
were in giving the carbonate of iron ; but as, in such cases, there is 
always more or less irritation and excitement of the nerves, it will 
be necessary to temper the action of the carbonate of iron, lest, by 
proving too stimulating, it may do more harm than good. I com- 
bined, therefore, with it a neutral salt of aperient and cooling pro- 
perties, the supertartrate of potash. It might be objected here, that 
an error was committed in prescribing remedies which are che- 
mically incompatible, and that so far the combination was imper- 
fect ; but it may be observed, that the supertartrate of potash is 
soluble with difficulty ; and, besides, even supposing that decom- 
position actually does take place, and that we have a tartrate of 
iron and a carbonate of potash formed, still we know that the 
tartrate of iron is an excellent chalybeate, and experience teaches 
us that the new combination forms an active and valuable remedy. 
To these ingredients we added sulphur, to act on the skin and the 
mucous surfaces of the lungs and digestive tube. You will re- 
collect that this girl had frequent attacks af tympanitis, which con- 
sists in an effusion of air into the intestines, produced by a fre- 
quently recurring congested state of the bowels. Now, strange as 
it may appear, sulphur, though apt to induce a secretion of sulphu- 
retted hydrogen from the intestinal mucous membrane, and thus 
give rise to flatulence, exercises by its gently stimulating and 

20* 



234 GRAVES'S CLLXICAL LECTURES. 

alterative effects a remarkable influence over morbid secretions of 
air from the bowels, and so far the homoeopathic doctrines seems to 
be borne out. It certainly appears singular that sulphur, which is 
a stimulant, and which generally increases the gaseous secretions 
of the digestive canal, should have a tendency to remove conges- 
tion and diminish flatulence ; but 1 appeal to experience and 
analogy for the truth of this opinion, and refer to its use in another 
form of disease where congestion and flatulence is always present, 
namely, in cases of hemorrhoids. So much for the reasons which 
led me to prescribe this combination. 

In ordering this electuary you should give directions (and this is 
a point never to be neglected in treating female complaints) to the 
patient to attend carefully to the effect of the remedy. If a tea- 
spoonful three times a day is sufficient to keep up a gentle but full 
action of the bowels, there will be no necessity of changing the 
dose; but if this is not enough, it should be increased, or it may be 
quickened by the addition of a small quantity of jalap or electuary 
of scammony. This, however, should be done cautiously, because 
in such cases your object is not to purge briskly, but merely to 
maintain a soluble state of the bowels. When the use of this 
electuary has been persevered in for some time, and when the 
patient takes it regularly, and knows the exact quantity necessary 
to produce one or two loose evacuations in the day, it is surprising 
how favourably it will act. It regulates the bowels, invigorates the 
tone of the intestinal mucous membrane, increases the appetite, im- 
proves the strength, and restores the healthy action of the nervous 
system. In the case before us it has proved eminently serviceable. 

So far with respect to our attempts to act on the system generally ; 
a few words now with respect to the local treatment. In the first 
place, with the view of strengthening the tone of the bladder, and 
promoting the expulsion of urine, we gave fifteen drops of the 
muriated tincture of iron (liquor muriatis ferri p. d.), in an ounce 
of camphor mixture three times a day. The reason for prescribing 
the muriated tincture of iron is so obvious, and it has been so fre- 
quently employed for similar purposes, that it is unnecessary to say 
anything in the way of explanation. In addition to this, I ordered 
a large vessel of cold water to be poured over her back and loinsj 
every day. This practice has often proved very beneficial to 
nervous females ; it has in many cases restored the power of thel 
bladder and improved the functions of the uterus; it also exercises 
a remarkable influence over the digestive system, and, like sea 
bathing, is an excellent remedy for constipation. In order to insure 
its full efl^ect, you should order the patient to place her feet in warm 
\vater, and have the cold water poured from a considerable height. 
Like many other remedies of a similar kind, it is difficult to explain 
its action, but experience has shown that it is extremely valuable. 
We next prescribed such remedies as contribute to promote the se- 
cretion and evacuation of the urine, and, lastly, we have given a 



RETENTION OF URINE. ' 235 

combination of tonics and stimulants. To-day I have ordered the 
following draught, to be taken twice daily: — 

K Decocti foliorum buchu, ^j. 

Tinctiirae ejusdem, ^as. 

Spiritus setheris nitrosi, ^ss. 

Tinclurse cantharidis, TTLij. 
Fiat haustus. 

I need not tell you, gentlemen, what the properties of buchu are: 
it is gently stimulant, sudorific and diuretic ; it acts as a tonic on 
the urinary system, and in chronic affections of the bladder has 
proved extremely useful. Of the sweet spirit of nitre it is unneces- 
sary for me to say anything, but a few remarks on the action of 
cantharides may not be improper. Being convinced that in this 
case the retention depended chiefly on temporary paralysis of those 
muscular fibres by means of which the bladder is enabled to 
evacuate its contents, it became necessary not only to act on the 
general system, but also on the parts affected, and we know from 
experience that cantharides exert a stimulant effect on the whole 
urinary apparatus. The tincture of cantharides, however, should 
be given with caution, and only in small doses, as it is apt to 
stimulate too powerfully if prescribed in large quantities. I should, 
however, have no objection that it increased in this case the pain 
which the patient experiences in passing water, as it is necessary to 
have some symptoms present indicating its action on the bladder. 
A small quantity, however, is generally sufficient in all cases of 
this description, and I have seen very good effects from doses of two 
drops three times a day. 

While I am on this subject, permit me to speak briefly on an op- 
posite state of the bladder, which is frequently observed in very 
young persons. A boy, perfectly healthy, but of a nervous tem- 
perament, studious, and extremely anxious about his lessons, is 
subject from his infancy to pass his water under him in bed. He 
is, suppose, arrived at the age of six or seven years, and has no 
disease; but still this habit sticks to him, and cannot be removed. 
The irritability of his disposition has been increased by injudicious 
correction ; he has been taken up at night and whipped ; he has 
been ridiculed during the day ; his infirmity has been made known 
to his companions, who call him nicknames; and in this way the 
habit has been rather confirmed than removed. Now you may 
happen to be consulted about such a case, and be asked whether it 
can be relieved or not. The matter appears, perhaps, trifling and 
ridiculous, but you may get more credit by curing a bad habit of 
this kind, than by removing an acute disease. Now what are you 
to do? In the first place, you must remove the boy entirely from 
all companions of his own age, who are acquainted with his bodily 
infirmity. In the next place, you must not allow him to be cor- 
rected or reproached, and you must adopt every moral means to 
diminish general irritability. The boy should not be too much 



236 GRAVES'S CLINICAL LECTURES. 

confined ; he should not be allowed to apply too closely to his 
lessons; and he should have generous diet, good air, and sea 
bathing. On these general principles I have cured several very 
obstinate cases with the use of infusion of buchu, with tincture of 
cantharides, in small doses. With respect to the use of cantharides, 
it struck me that the same medicine which would have the pro- 
perties of stimulating in large doses, might, when given in small 
quantities, have the property of increasing the tone of the bladder, 
and perhaps altering its mode of action ; nor in this expectation 
have I been disappointed. In a number of the Dublin Medical 
and Chemical Journal I have spoken of a remedy which appears 
to be adapted to such cases, namely, the Lycopodium clavatum, 
which grows on the Dublin mountains, and which is said to have 
stimulant and diuretic properties analogous to those of the Diosma 
crenata and Arbutus uva ursi. It appears to be a remedy well 
adapted to cases where there is a chronic irritability of the bladder; 
and it is stated by some German writers that it has produced very 
good effects in many chronic catarrhal affections of the bladder. I 
have not, however, time to speak of its properties at present, and 
beg leave to refer you to the paper in which I have spoken of it, 
which you will find in one of the late numbers of the Dublin 
Medical and Chemical Journal. 

A woman, named Anne Scarlet, was admitted on Saturday, cofl- 
cerning whose case it may be necessary to make a few observations. 
She states that she has been ill for the last eight days, and that her 
illness originated in cold, preceded by rigors, and followed by 
feverish symptoms. The general pyrexia had subsided at the period 
of her admission ; but she had some symptoms worthy of attention. 
Her pulse was 72, and regular; her skin rather cool, and her 
bowels natural ; but she complained of acute pain in the left side, 
■which, she said, came now and then, catching her breath, and pre- 
venting her from taking a full inspiration. This pain was so 
intense, and seemed to affect respiration so considerably, that, look- 
ing to its situation and its effects, you would at first sight be in- 
clined to think that it arose either from pleurisy or pericarditis. 
On examining the chest, however, by the stethoscope and percus- 
sion, we found the sound was clear and normal : there were no 
r^les present, and the respiratory murmur was heard distinctly over 
the whole lung. In fact, auscultation showed that the cause of 
the pain was not connected with pleuritis, pneumonia, or peri- 
carditis. What then was it? A variety of pleurodynia, well 
worthy of your attention, as being connected in her case with re- 
tention of the milk and engorgement of the left mamma. At the 
time she was attacked with cold, she happened to be only a few 
days after childbirth : the feverishness^which ensued obliged her to 
give up nursing, and in this way a sudden and unnatural check 
was put upon the secretion of milk. When an occurrence of this 
kind takes place, and proper means are not taken to obviate the 
mischief, a high degree of local irritation is the consequence, pro- 



TREATMENT OF FEVER. 237 

ducing inflammation of one or both the mammae, which, if not 
treated well and energetically, will certainly end in mammary 
abscess. 

What I wish to draw your attention to, however, at present, is 
this — that inflammation of the mamma, arising from retention of 
milk, is very apt to be attended with pleurodynia in one or more 
parts of the chest. The flow of milk to the breasts, three or four 
days after delivery, is very often accompanied by flying pleurodynia, 
and the formation of mammary inflammation, from the arrest of the 
lacteal secretion, is also very frequently attended with fixed pains of 
a pleuritic character. 

The treatment adopted in this case was very simple. In the first 
place, you endeavour to check the determination of fluid to the 
breast; and for this purpose you exhibit a purgative of an hydra- 
gogue kind, calculated to act briskly on the bowels. We gave a 
combination of infusion of senna, sulphate of magnesia, tincture of 
senna, and electuary of scammony, which acted six or seven times 
on the bowels, and tended materially to relieve, by derivation, the 
mammary congestion. In the next place, we directed our attention 
to the breast, and endeavoured to remove the milk, by the use of 
the syringe employed for that purpose. The milk may be removed 
from the breast by means of the syringe, or by sucking with a 
breast-bottle, and where the tenderness of the part is so great that 
neither of these modes can be employed, the next best means is 
diligent fomentation. This produces a constant oozing from the 
breast, and if the fomentation employed be made with a decoction 
of poppy heads, it has considerable efl^ect in abating pain and in- 
flammation. We also applied leeches in this case, not with the 
view of removing the pleurodynia, but with the intention of remov- 
ing its cause — mammary inflammation. By the use of means 
directed to the breast, you will find that we can remove all symp- 
toms of pleurodynia, and that the pain and difficulty of breathing 
will soon disappear. This is a simple case, but it is one of frequent 
occurrence, and it requires some tact and management for its suc- 
cessful treatment. 

To-morrow I shall speak on some other matters connected with 
the treatment of fever, and shall give some extracts from a pam- 
phlet on the medical effects of the chlorides of lime and soda, pub- 
lished some time ago by the Archbishop of Cashel, an erudite 
scholar, an accurate chemist, and an excellent man. You have 
frequently, since the commencement of the present epidemic, seen 
me use the chloride of soda in the treatment of fever with the best 
eflfects. Indeed, we have much cause to congratulate ourselves on 
the happy results of our fever treatment. Since the commence- 
ment of the session, there has been a vast number of cases in the 
hospital, some mild, but many very doubtful and dangerous ; yet 
we have not, as yet, lost a single patient. This is a circumstance 
well calculated to excite agreeable reflections. It is also pleasant 
to recollect how plain and simple our mode of treatment has been. 



238 GRAVES'S CLINICAL LECTURES. 

You have probably observed that, in the treatment of all the cases 
that came before me, I have not prescribed altogether a dozen 
grains of calomel; that 1 have very seldom ordered any kind of 
purgative medicine ; that I have been sparing in the use of leeches 
and cupping, and that I have not ordered a single patient to be 
blooded. This I am sure will appear strange to the various sects 
of pathologists and theorists whom I have seen, like so many waves 
succeeding each other, and whose doctrines were equally doomed 
to break on the solid and immovable shore of truth. I recollect 
how each doctrine arose, and made converts, and influenced prac- 
tice ; how each had its day, and then sank into that obscurity and 
neglect to which vain and profitless speculations are always 
destined. I recollect when it was the custom to commence the 
treatment of fever, by prescribing ten grains of calomel, to be fol- 
lowed by a bolus containing fifteen grains of jalap, or by a large 
draught composed of infusion of senna, epsom salts, and electuary 
of scammony. I rem.ember the time w'hen it was the fashion to 
bleed every case 'of fever which came into hospital, no matter what 
the stage of the disease might be, or what the condition of the 
patient was, at the time of admission. I recollect, too, when the 
prostration and weakness which accompanies local inflammation, 
particularly of the digestive system, used to be treated with wine 
and stimulants. In fact, so great was the difference of opinion 
among medical authorities, and so discordant was the practice 
employed, that an able and honest man declared, in a pamphlet 
published about sixteen years ago, that the treatment of fever was 
nothing but a farce, and that as many would recover under one 
form of treatment as under another ; or, in other words, that as many 
persons were killed by one form of treatment as by another. This 
appalling announcement of the truth met the public eye, and it was 
further confirm.ed by observing that the poor, particularly those 
located in remote country districts, who had little or no medical 
attendance, died in much fewer numbers than the rich, who lived 
in towns or in their vicinity, and who had every attention paid them 
which professional skill could devise. Various explanations of this 
dreadful fact were given ; and among the hallucinations of the day 
was the statement, that a poor wretched being, who lived on bad 
food, who ate nothing but potatoes and milk, or probably salt, and 
who was addicted to habits of intoxication, was better calculated to 
bear fever than the man w^ho lived well and led a regular life. 
The truth, however, is, that the rich were killed by the nimia 
diligenti medicorum, and the poor, w^ho had nothing to look to 
(to use a quaint expression of Dr. Rutty) but the providence of 
God, escaped. It is certainly an undeniable fact, that those who 
had plenty of medical attention, and took a great quantity of medi- 
cine, frequently died; while those who had no attendance, and 
took scarcely anyihing but water, generally recovered. Any 
observant practical physician, who is in the habit of treating fever, 
knows that there is no single principle on which it can be treated 



TREATMENT OF FEVER. 239 

successfully. Every epidemic is peculiar and distinct in its nature, 
and each consequently requires a distinct and peculiar mode of 
treatment. Hence the necessity of studying fever unbiassed by 
any preconceived notions, and independent of the trammels of dog- 
matism. With a person v^^ho observes in this way, who studies the 
disease as it is, and not as it is described ; whose practice is regu- 
lated, not by the doctrines of the schools, but by the results of in- 
vestigation, carefully weighed and considered ; with such a person, 
the treatment of fever will be simple and successful, and I believe 
that there is no disease in which success so much depends on treat- 
ment as fever. It is difficult to explain how it came to pass that a 
contrary opinion could be promulgated in Dublin. Something 
must be attributed to the neglect or incapacity of those whose duty 
it was to teach the truth. The chief cause may, however, be 
traced to the activity and zeal which inspired some, not only to up- 
hold their own branch of the profession, but to decry, I had almost 
said to defame, that which they were pleased to caW pure medicine. 
With characteristic inconsistence, however, these gentlemen, who 
declared that the treatment of fever was at best useless, readily 
engaged in its management in private practice, and while they pro- 
fessed openly their disbehef in the efficacy of any medicines, they 
busily employed themselves in prescribing pills and draughts with- 
out number for their own fever patients. That they thought their 
treatment of some value, might be gathered from their acceptance, 
their invariable acceptance of pecuniary remuneration from the 
sufferers' grateful friends, who little dreamed the while that the 
hands which, with automatic movement, so readily grasped their 
fees, belonged to persons who held, nay, who maintained, the 
opinion that the treatment of fever was all a farce. Posterity will 
scarcely give credence to this fact, and will probably refuse to be- 
lieve that such an opinion could have been advanced in what we 
are pleased to call an enlightened age, and an enlightened city. 
They will scarcely think I speak the truth in assuring them that a 
spirit of medical intolerance existed to such a degree at the time of 
the discovery of the stethoscope, that whoever in Dublin actively 
occupied himself in verifying the researches of the immortal 
Laennec — whoever availed himself of the new resources invented 
by this great physician, was sure to become an object, not merely 
of dislike, but of animadversion and ridicule, on the part of those 
who ought to have exerted their influence in endeavouring to ad- 
vance, and not retard, the progress of science. Happily for the 
character of the country, their endeavours have been frustrated, 
and the cause of truth has triumphed. Happily for the students 
and their future patients, those teachers are now most followed, 
who best explain, and most diligently illustrate, the phenomena 
observed by means of mediate auscultation. 



240 GRAVES'S CLINICAL LECTURES. 



LECTURE XXI. 

I SHALL refer briefly to some points connected with the case of an 
old man in the chronic ward, who died lately of inflammation of 
the lung. At the period of his admission, he had been ill for some 
time ; both sides of the chest, but particularly the left, sounded 
dull on percussion ; he had extensive bronchial respiration, and 
crachet rouille, in fact, it was a very bad case of double pneumonia, 
a disease which at his time of life is very seldom cured. We did 
all we could to arrest the progress of the disease ; w^e cupped him 
over the left side, gave him mercury so as to affect his system, and 
applied blisters to both sides of the chest, anteriorly and posteriorly. 
These were the only active measures which remained for us to 
employ; from the man's age, the weakness of his pulse, and the 
duration of the disease, we could not venture on general bleeding ; 
we could only attack the disease with local depletion, mercury, 
and counter-irritation. All these remedies were applied with great 
diligence, but unfortunate!}^ proved incapable of checking the dis- 
ease. His cough continued, respiration became more difficult, and 
though his mouth became affected, the dulness on percussion in- 
creased day after day ; and though the patient was removed into a 
warmer room, and every attention paid to his comfort, it w^as evi- 
dent that he was getting gradually worse. iVbout a fortnight after 
his admission, his expectoration assumed the purulent character, 
and it was obvious that the lung had passed from the stage of hepa- 
tisation into that of interstitial suppuration. He took the decoction 
of polygala, with Iceland moss and syrup of white poppies, but with- 
out any relief to his symptoms ; the disease increased, and he died 
on the nineteenth, sixteen days from the date of his admission. 

On examining the lung, the ordinary phenomena of pneumonic 
inflammation were discovered ; parts of the lung were in the state 
of gray hepatisation, others were infiltrated w^ith pus, and broke 
down easily under the finger. We found, too, that he had not only 
pneumonia, but also extensive pleuritis and pericarditis. The 
pleurisy had probably commenced about eight or nine days before 
his death ; the pericarditis was of an origin somewhat more recent. 

You may ask w^hy I did not recognise these affections before 
death. The reason is twofold. The man was in a very weak and 
hopeless condition, and both sides of his chest were sore from the 
blisters ; these are circumstances under w-hich I have strong ob- 
jections to torment a patient with examinations, and therefore I 
made none in this case. The other reason is, that in a patient who 
has been greatly reduced by some acute disease, new inflammations 
are apt to spring up with great rapidity, and with still greater 
latency. I remember a very remarkable case of the same descrip- 
tion which occurred at the Meath Hospital, where the patient had 
a very extensive inflammation of the pleura with exudation of lymph 



ABSCESS OF THE HEART. 241 

and effusion of a considerable quantity of fluid, and yet not one of 
these symptoms were recognised during life. This man, you will 
recollect, never complained of pain in the side, nor had he orthopnoea, 
irregularity of pulse, lividity of countenance, or any of those symp- 
toms which are looked upon as indicative of pericardial inflamma- 
tion, yet on dissection we find the pleura extensively engaged, 
lymph exuded on its surface, and a small quantity of sero-purutent 
efl^usion in its cavity ; and on examining the heart, we find the peri- 
cardium covered internally with an extensive gelatinous layer, con- 
sisting of lymph and puriform fluid intimately mixed together. 
You perceive, then, in this case, a confirmation of what I have so 
often insisted on, that pleuritis may occasionally run through its 
course, unaccompanied by pain in the side, and that inflammation 
of the pericardium may exist without orthopnoea, irregularity of 
pulse, lividity of countenance, or fainting, symptoms formerly be- 
lieved to be more or less manifest in every case of pericarditis. 
The pathology of pericarditis has been investigated but lately with 
the care it deserves : the labours of our French brethren have been 
mainly instrumental in producing its present degree of advance- 
ment. In England some valuable observations have been con- 
tributed by Dr. Elliotson and others, but they have been more than 
rivalled by the contributions to the diagnosis of this disease which 
have appeared in the Dublin Journal of Medicine and Surgery. 
The French, indeed, have afforded the strongest evidence of the 
high value they attach to the essay of Dr. Stokes on the subject 
of pericarditis, by the transference of his entire article to the 
pages of the Archives Genirales de Medecine. A most masterly 
paper, by Mr. Mayne, in the twentieth number of the Dublin 
Journal^ ought to be consulted by every one anxious to make 
himself master of this important subject. Indeed I have no hesi- 
tation in asserting that Mr. Mayne's paper will be found capable of 
bearing a comparison with anything yet written on the symptoms 
of pericarditis ; compare it, for instance, gentlemen, with the article 
Pericarditis, by Dr. Hope, in the CyclopcBdia of Practical Medi- 
cine, and you will at once perceive the very great inferiority of 
the latter ; compare it and Dr. Stokes's paper with the reports of 
clinical lectures delivered in London on cases of pericarditis, and 
you will agree with me in thinking that the writings of our coun- 
trymen yield not in merit to those of the metropolitan professors. 
Gentlemen, I speak not in the spirit of vanity ; I do not bring these 
matters forward in order to flatter and augment a feeling of medi- 
cal nationality ; far be it from me to extol beyond their deserts the 
merits of Irish writers, still farther from me the wish to depreciate 
the labours of English authors. Let us emulate our neighbours in 
the spirit of honest rivalry, and not imitate the example of some 
London lecturers and Scottish reviewers, who — but I have done, 
fearing that the narrow-minded prejudices of an editor in Edin- 
burgh, or of a few teachers in London, should induce me to forget 
the favourable, the too flattering reception, which everything of 

21 



242 GRAVES'S CLINICAL LECTURES. 

merit issuing from the press of Ireland has met with from the 
medical periodicals of England. 

To return to our subject. Pericarditis is a disease of quite as 
frequent occurrence as pleurisy, and often, as in the present in- 
stance, associated with the latter ; on the whole, I do not consider 
pericarditis as more dangerous or more difficult to cure than pleu- 
ritic inflammation, neither does its existence seem less easily ascer- 
tained. Some cases, it is true, are extremely insidious in their 
nature, but the same may be said of cerebritis, pneumonia, and all 
other phlegmasia ; usually, however, a careful and attentive physi- 
cian will at once detect the existence of pericardial inflammation. 
When he finds that a patient has been exposed to causes capable of 
exciting fever, that he has been Hable to gout or rheumatism, or has 
been actually attacked with either, then will his attention be directed 
to the heart ; if he perceives that its action is either unusually vio- 
lent or irregular, or if he observes that uneasiness and oppression 
of chest are complained of to a degree not to be accounted for by 
any pulmonary lesion present ; if he finds that his patient has the 
appearance of a person labouring under some serious disease, and 
that none such exists in the lungs themselves, then w^ili he be 
called onto examine the region of the heart with the greatest accu- 
racy. One of the most common symptoms of pericarditis is tender- 
ness in the intercostal spaces over or near the heart. This is not] 
perceived in many cases until pressure is made with the fingers.' 
Tenderness occurs in many who do not complain of pain or stitchj 
in this portion of the chest ; when the latter co-exists with tender- 
ness, the presumption in favour of the presence of pericarditis is^ 
still greater. The pain and uneasiness about the heart, are, as Dr. 
Elliotson remarks, generally increased by pressing in the left hypo- 
chondrium upwards towards the diaphragm. I must refer you to 
Dr. Stokes's and Mr. Mayne's papers for any analysis of the physi- 
cal signs derived from percussion and auscultation, and also for aal 
explanation of the reasons why the general symptoms are subjecti 
to such striking variations in this disease. In some you have,! 
soon after its commencement, lividity, orthopnea, and tendency toj 
fainting combined w^tji irregularity of pulse ; in others the disease \ 
runs its whole course, vrhether it terminates fatally or in health,! 
without any of these symptoms; in fact, no disease is more incon-i 
stant in its characters, and none more requires the aid of investiga- ] 
tion by means of physical signs, which, if well conducted, seldom, 
fails to clear up all doubts. Of one thing I am certain, that inflam- 
mation of the pericardium in a person of tolerably good constitutioa 
may be generally arrested in its progress by bleeding, frequent 
leeching, and scruple doses of calomel. It is mere trifling on such 
occasions to have recourseto tartar emetic, digitalis, or the common 
antiphlogistic remedies. Instantly use every effort to produce the 
full action of mercury on the system. Apply the ointment to the 
axillffi ; smear it over the inside of the thighs ; make your patient 
respire the vapour of hydrargymm cum cretd as often in the day 



ABSCESS OF THE HEART. 243 

as he can bear the process, and be assured that you are pursuing 
the proper course. Well has it been observed by Dr. Elliotson, 
when speaking of a fatal case of pericarditis, — " The only chance 
I had to save the life of this person would have been to have pushed 
the mercury further. I am quite sure that more lives are saved in 
inflammatory diseases by carrying mercury to a great extent, than 
by merely having recourse to it for the simple production of pty- 
alism." It is the want of decision in the practice of the French 
physicians — it is to their want of confidence in mercury, that we 
must attribute the greater mortality of pericarditis in Paris than in 
Dublin ; for most of our patients recover, most of theirs die.* Of 
course, gentlemen, the most unfavourable of all cases is where 
pericarditis attacks a person debilitated by previous sickness, such 
as fever, dropsy, &c. Here the disease runs a very rapid, and too 
often a fatal, course, and cannot be controlled. One practical 
remark, and I have done. Before effusion takes place into the 
pericardial sac never apply abHster; after it has occurred, repeated 
and severe blistering over and about the region of the heart is one 
of our best remedies. 

Two years ago I had an opportunity of studying a case which 
subsequently proved to be an example of inflammation of the mus- 
cular substance of the ventricles, ending in suppuration and the 
formation of a large abscess in the ventricular parietes. This is a 
very rare occurrence, for the simple reason, that inflammation of 
the substance of the heart generally proves fatal before pus is 
formed. A very robust gentleman, aged fifty-five, from the neigh- 
bourhood of Wicklow, came to Dublin for the benefit of advice. 
He had complained of cough for many months, together with dys- 
pnoea and palpitation of the heart ; latterly, he had become anasar- 
cous, and suffered much from distress and pain referred to the 
region of the heart. This pain formed the chief subject of his 
complaint, and darted over the chest. On examination, I imme- 
diately detected hypertrophy and dilatation of both ventricles, and 
I announced the existence of valvular disease, inasmuch as a loud 
and extensive hruit de soufflet existed, together with a remarkable 
frSmissement cataire, and a very irregular pulse. This opinion 
w^as delivered in the presence of Dr. Sherwood and Mr. Hethering- 
ton. Our patient returned to the country, where he continued to 
complain of pain in the heart that was at times excruciating. He 
died suddenly at the end of a few weeks. The results of the post- 
mortem examination were kindly communicated to me by Dr. 
Sherwood. Considerable dropsical effusion into both pleural 
cavities ; heart exceedingly enlarged. " On splitting open the peri- 
cardium, I found (says Dr. Sherwood) that the heart adhered to its 
entire surface by means of bands of coagulable lymph, which were 

* [A complete error ; in all countries the disease is rarely fatal, and in France 
it was first ascertained by Dr. Louis that it generally terminated favourably. — 



244 GRAVES'S CLINICAL LECTUKES. 

easily broken down except at the apes of the heart, where they 
were very strong and firm. In attempting to break them, more 
than two ounces of purulent matter escaped into the cavity of the 
pericardium, which caused me to institute a very close examination 
of the parts, in order to discover whence the pus came. I found a 
small rent in the apex of the heart, immediately below the floor of 
the left ventricle, exactly in the situation of the firm adhesions before 
spoken of. On enlarging this opening, I discovered a cavity in the 
substance of the heart, with a regularly-defined wall capable of 
containing more than two ounces of fluid. The walls of both ven- 
tricles were enoraiously thickened : all the valves were more or 
less affected : but the chief disease lay in the semilunar valves of 
the aorta, which were nearly altogether ossified." 

This case was extremely remarkable, and exhibits an example 
not merely of the dropsy and dyspnoea which so usualh^ attend 
hypertrophy and valvular disease of the heart, but also of a combi- 
nation of chronic pericarditis and chronic inflammation of the mus- 
cular substance of the ventricles, e-ndin^ in the very rare terj/iina- 
tion. abscess. 

Having made these observations, I shall next call your attention 
to the disease of Francis Thorpe, which is important both in itself 
and from the circumstance of such cases being frequently met with. 
This lad, who was much exposed to the weather, being an outside 
servant, was attacked about six months ago with cold, followed by 
hoarseness and sore throat, with cough, then slight, but at present 
rather troublesome. A certain degree of rawness about the fauces 
was observed soon after the attack, and latterly the submaxillary 
glands have become slightly enlarged. On looking into the throat, 
the velum and fauces appear redder than natural, the amygdalae 
are swollen, and the mucous membrane covering the back and sides 
of the pharynx is dry, and covered with irregular superficial exco- 
riations. The hoarseness still continues, and he can only speak in 
whispers. His general health, however, does not seem in any de- 
gree impaired ; he has no fever, his appetite is good, and his sleep 
natural. 

This case, however, is one which deuiands particular attention. 
A boy is attacked with cold, he gets slight local inflammation of the 
fauces and larynx ; this produces cough and hoarseness, which go 
on for months rather increasing than diminishing, and his symp- 
toms finally assume a chronic and intractable character. Still he 
does not fall away in flesh, has no symptom of hectic, and, on 
examining his chest, you cannot find any evidence of the existence 
of tubercles. In making the prognosis in such a case, you should 
always act with great caution. Though an examination of the 
chest should detect no distinct sign of tubercles, and a review of 
the state of the constitution should satisfy you that there was no 
fever, night sweats, or wasting of flesh, yet the obstinacy and per- 
sistence of the inflammatory condition of the larynx and fauces 
would seem to show that the affection, though not decidedlv of the 



CHRONIC LARYNGITIS. 245 

scrofulous character, was still more analogous to it, and might end 
in phthisis. You should not be so sanguine as to anticipate a cer- 
tain cure, because the cough and laryngeal symptoms are unac- 
companied by fever, or by stethoscopic phenomena indicating the 
approach of phthisis. The disease, by fixing itself in the larynx, 
and keeping up a constant irritation in the neighbourhood of the 
lungs, would probably, after some time, (if exacerbated by fresh 
colds and confirmed by neglect,) give rise to tubercular develop- 
ment. 

Allow me to allude here briefly to a form of chronic laryngeal 
inflammation which has been described under the name of phthisis 
laryngea. Of this disease there are two varieties. In one case 
the hoarseness and sore throat follow the development of tubercles 
in the lung ; in the other they precede it. Consumptive persons 
very frequently get, shortly after the occurrence of scrofulous 
inflammation of the lungs, sore throat, hoarseness, and laryngeal 
cough. But this is different from the hoarseness and cough which 
precede phthisis. In the former, the laryngeal symptoms are 
secondary, and form only a part of the general disease ; in the 
latter, they constitute the first link in the chain of morbid action. 
The former take place only in a constitution decidedly scrofulous ; 
the latter occur most commonly in constitutions which have been 
impaired by various debilitating causes, and thereby rendered 
analogous to, or identical wdth, the scrofulous. One disease, how- 
ever, explains the other, for it is clear that if a certain state of the 
constitution is capable of occasioning scrofulous inflammation of 
the lungs and tubercular development in the pulmonary tissue, in 
the first instance, and laryngeal disease in the second, it is clear, I 
say, that the order of succession may be very easily inverted, and 
that, in such a constitution, the accidental circumstance of a cold 
falling on the larynx may determine the appearance of disease in 
that part long before the lungs become engaged. Hence, whenever 
you are called on to treat a case of chronic laryngitis, where the 
disease has lasted for any length of time, and where the patient's 
system has been impaired by any debilitating cause, or where you 
have any reason so suspect that he is of a strumous diathesis, your 
prognosis should be always guarded. 

You should not, however, give up the case at once, particularly 
if an examination of the chest assures you that there is no scrofu- 
lous deposition going on in the lung. In the first place, endeavour 
to remove the inflammation of the throat, if possible ; by doing this, 
you will accomphsh a vast deal ; and in the next you should direct 
all your efforts towards improving the state of the constitution, for 
in this way you make the greatest progress in checking the ten- 
dency of the individual to scrofula. If there be much tenderness 
of the larynx on pressure, as you can easily ascertain by placing 
your finger and thumb on each side of the thyroid cartilage, press- 
ing the larynx backwards, and moving it from side to side, you 
should commence with the local detraction of blood. A small 

21* 



246 GRAVES'S CLINICAL LECTURES. 

number of leeches should be applied to the throat every second or 
third night, and this should be continued for a week or a fortnight. 
If there be no tenderness of any amount, and the patient can bear 
pressure freely, there is no necessity of applying leeches. Your 
means must then be confined to those remedies which act imme- 
diately on the diseased mucous surface, and for this purpose, one 
of the best applications is a solution of nitrate of silver, ten grains 
to the ounce, or a solution of the sulphate of copper, in the same 
proportions. The best mode of applying it is to take a probang, 
or a small piece of sponge, fastened to the end of a quill, dip it in 
the solution, and having slightly squeezed it to prevent the fluid 
from dropping, touch the excoriated and red parts of the fauces as 
far as you can conveniently go, rather by pressing the sponge 
gently against the inflamed mucous membrane than by rubbing. 
It will be essentially necessary to touch every portion of the dis- 
eased surface of the pharynx, for if any part be omitted, it will 
have the eflfect of keeping up the disease. You perceive the object 
here is to change the action of the mucous membrane. By acting 
powerfully in this, way on the mucous membrane covering the 
pharynx, fauces, and entrance of the larynx, you will often succeed 
in bringing on a healthy action, which spreads to the parts in the 
vicinity. Of this we have an illustration, afforded by the results 
of treatment in chronic disease of the skin, where local applica- 
tions to a particular part not only cure that part, but also extend 
their influence to a considerable distance on every side. It is the 
same with respect to irritation or inflammation of the lower part of 
the digestive tube; the use of astringent injections, which can only 
affect the lower part of the rectum, is often found of essential ser- 
vice in relieving dysenteric affections of the colon. 

In addition to the use of the nitrate of silver,^ we have employed 
a remedy in this boy's case which has been found beneficial in' 
several instances where no sign of pulmonary irritation is present 
— I allude to the use of iodine inhalations. This was also intended 
to make a still further change in the condition of the diseased 
mucous membrane. It is made by putting from five to ten drops 
of the tincture of iodine with half a dram of tincture of conium, 
and four ounces of hot water, into an inhaler, and making the patient, 
draw the vapour into his throat for about ten minutes, every night 
and morning. This form of inhalation proved extremely service- 
able in the case of a gentleman who has attended my lectures this^ 
winter. About the commencement of November, while in a deli- 
cate state of health, he was attacked with cold, and got sore throat, 
followed by slight huskiness of voice, and hard, incessant, laryngeal 
cough. These symptoms continued during December and the 
greater part of January, and were not completely removed until 
the beginning of February. He had considerable rawness of the 
back and sides of the fauces and larynx ; we observed that the 
mucous membrane of those parts had a strong tendency to become 
excoriated, for whenever an exacerbation of his symptoms occurred, 



CHRONIC LARYNGITIS. 247 

and that his cough in the morning was harder than usual, small 
portions of the detached pellicles of lymph, exuded by the mucous 
membrane, came way at each fit of coughing, and his sputa were 
tinged with blood. There was another symptom in this case, 
which you will very frequently meet with in similar instances, 
namely, a remarkable feeling of chilliness in the integuments of 
the fore part of the neck and external fauces. This he was in the 
habit of remarking, and could always foretell the occurrence of an 
exacerbation of his laryngeal symptoms, by the increased feeling 
of cold in the cutaneous surface over the diseased parts. In this 
case, a great deal of good was effected by the inhalation of iodine 
with conium. The mode in which this gentleman employed it, 
was by dissolving from six to nine grains of the extract of conium, 
in hot water, and then adding the tincture of iodine. Instead of 
the common inhaler, which contains but a small quantity of fluid, 
and in which the inhalation becomes cold in a very short time, he 
employed for the purpose a high old-fashioned teapot, which con- 
tained a large quantity of fluid, and could be used for a much 
longer period. Under the use of this, with counter-irritation, and 
the internal use of iodine with sarsaparilla, the laryngitis disap- 
peared ; it returned, however, about a month afterwards on fresh 
exposure, but was speedily removed by the use of the nitrate of 
silver solution. 

Another thing which we have prescribed for this boy, and which 
proves an excellent adjuvant in the treatment of such cases, is 
counter-irritation by croton oil frictions. To an ounce of com- 
pound camphor liniment, we add twenty or thirty drops of croton 
oil ; and of this lotion about one or two drams are to be rubbed 
over the parts, night and morning, until the eruption appears. Two 
rubbings are generally sufficient to produce a copious eruption of 
papulce about the size of a pin's head, and having exactly the ap- 
pearance of a disease at present very rare — the eczema mercuriale. 
We have not, however, been able to effect any remarkable 
improvement in this boy's symptoms, by the means to which I 
have just now alluded ; and the question is, what other remedies 
have we left, from which we could hope to derive any advantage? 
The boy has no fever or emaciation, his appetite is good, his sleep 
regular, and the stethoscope informs us that there are no symptoms 
of tubercular development ; we are therefore, I think, authorised in 
attempting to arrest the disease by the only means of which we 
have a choice under such circumstances. It is my intention to 
attempt its removal by mercury, and I have therefore ordered him 
to take, three times a day, half a grain of calomel, three grains of 
blue pill, with a grain of the extract of conium ; and, instead of 
iodine, we have directed him to inhale the vapour of hydrargyrum 
cum creta twice or three times daily. If, however, we find that 
this does not produce speedy improvement of his symptoms, we 
shall stop it immediately, as the use of mercury in such cases is 
generally a perilous experiment. I shall also take care to pay 



248 GRAVES'S CLINICAL LECTURES. 

attention to the general state of his health, as this is a matter of 
great importance in cases of chronic disease. I had almost for- 
gotten to observe that in such cases the use of the decoction of 
sarsaparilla with nitric acid has been found extremely beneficial. 
There is one point in the treatment of chronic laryngitis which you 
should never forget — and that is, to make the patients refrain as 
much as possible from speaking. Unless they do this, you will find 
it very difficult to effect a cure. A person with an inflamed larynx, 
who exercises his voice as usual, acts as foolishly as a man w^ho 
reads with inflamed eyes, or walks with a sprained ankle. The 
only thing I have to add with respect to the treatment of this dis- 
ease is, that the patient should be kept as much as possible in an 
equal temperature, and hence it will be necessary, in many in- 
stances, to confine him to the house, or at least to prevent him from 
exposing himself to a cold and damp atmosphere. When he reco- 
vers, he should use cold gargles and cold lotion to the throat, in 
order to render the parts less susceptible of cold. 

Allow me now to direct your attention to two cases oi prurigo 
which have been recently admitted. The first is that of J^ne Cas- 
sady, a woman advanced in life, but of tolerable good constitution, 
considering her age, station, and circumstances. About three months 
before admission, a rash appeared over her arms, legs, and body,, 
w^hich was preceded and accompanied by pain of the stomach, head,, 
and limbs, with recurring rigors. As far as we can learn from her 
description, this appears to have been urticaria ; of this, however, 
we cannot by any means be certain ; and besides, it is of little con- 
sequence, as prurigo may come on without it. She is at present 
labouring under prurigo senilis, not thickly disseminated, but still 
a source of constant. annoyance to her from the intolerable itching 
it produces. Several of the papulse have formed dark red crusts, 
but this is in consequence of their bleeding from being scratched. 

This affection has been so well described by writers on cutaneous 
diseases, and is so easily recognised, that I shall not take up your 
time in detailing its characters ; a few circumstances connected 
with treatment, however, should be mentioned as deserving your 
notice. In the first place, I may observe that prurigo is a most 
harassing complaint, and, if not checked, has a tendency to under- 
mine the constitution by disturbing the patient's rest. The warmth 
of the bed-clothes, by increasing the vascularity of the skin, occa- 
sions an aggravation of the symptoms ; the patient passes a mise- 
rable and restless night, and rises in the morning quite unrefreshed. 
This, in process of time, gives rise to a kind of febrile condition of 
the system; the mouth and fauces become dry; the appetite is 
impaired; the secretions deranged, and debility and emaciation 
gradually produced. It is a disease which has broken many a 
constitution, which, previous to its accession, was to all appearance 
unimpaired and healthy. 

Prurigo has been confounded with common itch, but if you exa- 
mine the parts it occupies you will easily distinguish them. It is 



PRURIGO. 249 

most likely to be confounded with the small vesicular itch, where 
the vesicular papulse (this is the most expressive term I can think 
of) are extremely minute. There is a papular itch, and there is 
also one which is intermediate between the vesicular and the papu- 
lar ; it is with the latter that prurigo is most apt to be confounded. 
The difference between them, however, may be recognised by 
observing the parts of the body on which they appear. Itch gene- 
rally attacks the extremities, and particularly the inside of the joints, 
and the spaces between the fingers. Prurigo, however, does not 
occupy the same situations. If you examine this woman, you will 
not be able to find any trace of the eruption about the joints or 
between the fingers — and this circumstance is of itself sufficient to 
make the distinction, for itch would not have lasted for three 
months without attacking these parts.* I may also observe, that 
prurigo senilis is generally accompanied by derangement of some 
of the important secretions of the body, but particularly of the 
urine. Its appearance is in many instances preceded by a scanty 
flow of urine, and it is frequently accompanied by the deposition of 
a copious whitish sediment, which is the lithate of ammonia. This 
observation is worthy of attention, because it furnishes us with a 
hint towards the treatment, of which we may sometimes avail our- 
selves with great benefit to the patient. You will, in such cases, 
often efl?ect a great deal by the use of diuretic medicines — as cream 
of tartar with decoction of juniper berries and squill ; or with the 
more stimulant diuretics — as turpentine and cantharides. It will 
be also good to vary these remedies according to the circumstances 
of the case, and they should be always given in combination with 
medicines calculated to act beneficially on the digestive organs. In 
this case, we have given decoction of sarsaparilla with nitric acid 
for the last two days ; before this we gave cream of tartar with 
powdered bark. These are some of the best medicines which can 
be used internally. in the treatment of prurigo senilis. It is, how- 
ever, a very obstinate disease, and you will be often obliged to try 
many internal and external remedies before you can hit on one that 
will prove serviceable. Cooling diuretic aperients, aperients com- 
bined with tonics, and the decoction of sarsaparilla with nitric acid, 
— these are the chief internal remedies ; as to external ones, they 
are extremely numerous. In the present case we have, in the first 
place, directed the patient's body to be washed with a lather of soap 
and warm water every night and morning. The water for this 
purpose should be used as hot as the patient can bear it, and a very 
soft brush or sponge should be employed. In prurigo, a vast deal 
of good has been done by merely washing the itchy parts with soap 
and warm water; how it acts I cannot say, but I have seen a great 

♦ [There is often much difficulty in these cases, because inveterate itch is 
usually attended with prurigo; although the converse of this is not exactly 
true. The true itch is always vesicular at first, before the epidermis has become 
destroyed, and the little ridges which contain the insect lodged under the skin 
may generally be detected near the vesicle, and running towards it. — Ed.] 



250 GRAVES'S CLINICAL LECTURES. 

deal of advantage derived from a long-continued perseverance in 
its use. After this you may have recourse to more powerful appli- 
cations — such, for instance, as sponging the parts at bed-time with 
hot whiskey and laudanum, a pint of the former to a dram of the 
latter. Here you have the stimulant effect of the whiskey, the 
narcotic of the laudanum, and the peculiar action of heat on the 
skin, all combined, and calculated therefore to make a very decided 
impression. How this effect of heat is produced I cannot tell, but 
we all know that, whether applied in a moist or dry form, it exer- 
cises a powerful influence over the vascularity and nervous vitality 
of the skin. Neither can I tell you what description of cases are 
most likely to benefit by it ; some cases of prurigo senilis are much 
relieved by warm applications, others are not : you should, how- 
ever, always make a trial. 

There was one application used in this woman's case, to which 
I shall briefly call your attention. A dram of acetate of lead was 
dissolved in two onnces of Tvine vinegar mixed with the same 
quantity of water, and this was rubbed up with olive oil so as to 
form a hniment. Mr. IXalty, who mixed -up the ingredients, says 
that three ounces of olive oil were absorbed. You are aware that 
oil conducts itself, with respect to the metallic oxides, as it does 
"with the alkalies. This formed a liniment, which, when allow-ed 
to stand, separates; but its ingredients are at once mixable by 
shaking the bottle. From its use the woman has derived great 
relief, and I can recommend it to you as one of the best applica- 
tions in prurigo. 

Before I conclude this lecture, I shall allude briefly to the very 
interesting case of Sarah 0*Xeil. This young woman was admit- 
ted on the 17th of February, having been attacked, on the 10th, 
"with fever of the ordinary type. On the day after her admission, 
she complained of want of sleep., and pain of the forehead and 
temples ; but she had no raving, tinnitus aurium, intolerance of 
light, or other symptoms of inflammation of the brain. She had 
been confined about a fortnight before she came in, and complained 
that her breasts were very troublesome to her. Her belly was soft 
and fallen, quite free from tenderness or soreness, and she stated 
that her bowels were free. Her tongue was furred, her pulse 130, 
the lochia suppressed for the last two days. Things went on tole- 
rably well for four or five days, when her belly became tympanitic, 
and she began to complain of pain on pressure. The action of the 
heart now became more violent; her pulse rose to 140, and blood 
began to appear in her stools. Cn the 24th of February — that is 
to say, about the fourteenth day of her illness — her pulse was 150; 
she passed a large quantity of blood from the bowels, and the tym- 
panitis subsided. 

In cases of fever accompanied by tympanitis and signs of intes- 
tinal congestion, hemorrhage from the bowels, particularly when it 
occurs on one of the critical days, should not be interfered with. 
It is in this way that nature very frequently brings about relief of 



PRURIGO. 251 

the congestion and irritation of the gastro-intestinal mucous mem- 
brane, just as she relieves congestion of the head by bleeding from 
the nose. In the case of a lady whom I attended along with Mr. 
Palmer, some time ago, at Drumcondra, the occurrence of intestinal 
hemorrhage was followed by the most marked effects ; her belly 
became soft, the tympanitis disappeared, and all her febrile symp- 
toms were speedily removed. The appearance of blood, therefore, 
at such periods and under such circumstances, is to be looked on 
as a favourable occurrence ; nor should it be interfered with in any 
way until, from its continuance or its quantity, it appears likely to 
produce debilitating effects. In the present case, however, this 
hemorrhage will require to be very carefully watched. The 
woman's system is in that state which is favourable to profuse 
fluxes of blood, for it is not long since her accouchement, and she 
has had suppression of the lochia. She has had but little fever for 
the last two or three days, but the action of the heart still continues 
extremely violent, and her pulse is still rising. Respiration, too, 
has been considerably accelerated; and, where this occurs, you 
have always reason to apprehend danger. I have accordingly en- 
deavoured to moderate the hemorrhage by the use of acetate of 
lead and opium. A draught composed of* two grains of acetate of 
lead, eight minims of tincture of opium, and fifteen minims of wine 
vinegar in six drams of water, has been prescribed to be taken as 
occasion requires. A large blister has been applied, so as to cover 
the epigastrium and sternum, and she has been allowed port wine 
and chicken broth. Where a patient, debilitated by previous fever, 
has been attacked with hemorrhage, you should b^ careful in sup- 
porting the system by small quantities of wine, and light nutritious 
food ; for there is always more or less danger to be apprehended 
of a sinking of the powers of life. In cases of this kind the cautious 
use of acetate of lead, with opium and wine, are the only means on 
which we can rely with any confidence. 

I regret that time will not permit me to make any further obser- 
vations on this very interesting case ; I shall, however, resume its 
consideration at our next meeting. 



END OF THE TIRST SERIES. 



CLINICAL LECTURES 



SECOND SERIES 



LECTURE I. 

Introduction — Connection between diseases of diiFerent organs ; between arthritis, 
jaundice, and urticaria ; between periostitis, produced by abuse of mercury, and 
hypertrophy of the liver — Details of cases illustrating this connection — Its expla- 
nation — Hypertrophy of the liver produced by scrofula — Enlargement and inflam- 
mation of the liver after scarlatina — Importance, of recognising this disease. 

Although it is customary to state at the commencement of a 
course of clinical lectures, the mode of instruction the teacher 
intends to pursue, it is not my intention to dwell on the plan of 
communicating medical information adopted in this hospital, or the 
facilities, advantages, and inducements which it affords. I have 
spoken so often on the subject, and my opinions have been so long 
before the public, that I do not feel it necessary to enter into details 
on the present occasion. It is extremely satisfactory to me to find 
that the mode of clinical instruction which I introduced at this 
hospital in 1822, has been adopted in most of the Dublin hospitals, 
and in many of the medical institutions of Great Britain. It is now 
several years since I delivered an introductory lecture at the old 
Meath Hospital on the Coombe, setting forth the insufficiency of 
the clinical instruction imparted to the students in Dublin at that 
period, and proved, to the satisfaction of my auditors, that the 
German mode was infinitely superior. The lecture 1 then de- 
livered was subsequently published in the London Medical Gazette.* 
This mode I soon afterwards introduced at this hospital, and it is 
a source of extreme gratification to me to find it adopted and ap- 
proved of by so many medical teachers of established reputation. 
It is recommended at once by its simplicity, and by its admirable 
fitness for fulfilling the purposes which it is intended to accomplish. 
A card is suspended over each patient's bed, on which is recorded 
the date of his adnpission, the history of his case, and the daily 

* See Medical Gazette, vol. x. p. 401. 



DISEASES OF DIFFERENT ORGANS. 253 

treatment, dietetic as well as medical. These cards remain in the 
wards until the patient leaves the hospital, and in this way any 
gentleman who wishes to observe the progress and termination of 
any particular case, can easily make himself master of its principal 
features, and the different remedial agents employed for its allevia- 
tion or removal. I shall not dwell any longer on this subject, as 
my object at present is to excite you to a diligent cultivation of the 
many and valuable opportunities which this institution affords. Go 
round the wards, and observe the numerous and varied forms of 
disease they present. You will find in them many examples of 
morbid affections, interesting alike to the student and the practi- 
tioner, and capable of affording practical lessons of inestimable 
value. He must be sadly deficient in zeal, attention, and every 
other quality necessary to constitute the accomplished and success- 
ful physician, who does not feel himself excited to study by what is 
there presented to his observation. 

Did time permit, I should be glad to furnish you with an outline 
of the most interesting cases which have been under treatment in 
our wards for the last three months, in order to give you some idea 
of the prevailing forms of disease, and their most remarkable mo- 
difications; and in this way to prepare you for studying with more 
advantage the cases that may come under your notice during the 
ensuing session. We have had some cases of extreme interest 
during the months of August, September, and October; but 1 fear 
even a brief review of these would occupy more time than I could 
conveniently devote to the subject, and would interfere with matters 
of paramount importance. I have, however, kept records of these 
cases, and shall feel most happy to show them to any gentleman 
who may be anxious to peruse them. Before I proceed to make 
any observations on the cases at present in our wards, I shall give 
a statement of the most remarkable results obtained in the chronic 
■wards, and the most important pathological observations made in 
the fever wards during the last three months. This will occupy but 
two or three lectures, and in the interim I shall each day direct 
your attention to anything of importance which occurs in the w^ards. 
It is my intention at present to limit myself to the illustration of 
some points connected with pathology, and to dwell merely on those 
prominent features of disease which bear a special reference to 
practical medicine; I shall afterwards give some lectures on fever. 
I shall not enter into any disquisition as to the origin and cause of 
fever ; for these matters you must consult your books : all you can 
expect from me is to endeavour to impart to you some useful hints 
on the treatment of fever. 

In order to acquire a correct and- available knowledge of human 
pathology, and to extend the range and confirm the accuracy of 
diagnosis, it is of the utmost importance to observe attentively the 
connection between the diseases of certain organs or systems of the 
body. You are aware that some organs, when labouring under 
disease, are apt, after the disease has continued some time, to im- 

22 



254 GRAVES'S CLINICAL LECTURES. 

plicate other organs, giving rise to various- deranged conditions 
which are developed, sometimes simultaneously, but in general con- 
secutively, and in sequence. I have already pointed out several 
diseased actions thus associated together, each forming a link in 
the morbid chain. Now it is of the greatest importance to study 
each link, and ascertain the nature of its connection, so as to have 
a distinct conception of the whole. Last session 1 directed the 
attention of my class to a train of morbid phenomena sometimes 
observed co-existing with arthritic inflammation. A person labour- 
ing under inflammation of the joints gets an attack of hepatitis, 
accompanied by jaundice, and this is followed by urticaria. I have 
observed this sequence of disease in eight or nine cases. The first 
was in a gentleman residing in Lower Mount street, whom I at- 
tended with Dr. Cheyne. This gentleman, in consequence of 
exposure to cold, was attacked with arthritic inflammation and 
fever. After he had been about ten days ill, he became suddenly 
jaundiced, and in a day or two afterwards a copious eruption of 
urticaria appeared over his body and limbs. Exactly the same 
train of phenomena, and in a similar order of succession, were 
observed in a man treated in the Meath hospital in 1832. A short 
time before this I had been attending a medical friend in Baggot 
street, who had been aflfected in the same way ; and I mentioned to 
the class, as soon as I perceived the man was jaundiced, that he 
would most probably get urticaria. I made a similar prediction in 
a case which occurred recently in our wards, and it was verified 
by the event. Now this is not a mere fortuitous occurrence ; the 
various symptoms must be connected in the relation of cause and 
eflfect. It is interesting to bear this in mind, and it is besides of 
considerable importance to the practising physician; it enables him 
to predict the appearance and form of disease, and inspires his 
patient with confidence in his opinions and judgment. 

There is another sequence of disease not unfrequently observed, 
but of which the connection has not been hitherto noticed by any 
writer, as far as I can ascertain. About two years since, Mr. 
Crampton and I were consulted by an English gentleman, who 
had been ill for a considerable time. The history of his case from 
the commencement was this : — Three years previously he had 
venereal — used and abused mercury — was exposed to cold, and got 
periostitis. He now got into a bad state of health, used mercury 
a second time, obtained some relief, and then relapsed again: 
finally, after having used mercury three or four times, he was at- 
tacked with mercurial cachexy, became weak and emaciated ; the 
periostitis degenerated into ostitis, producing superficial caries and 
nodes of a bad character ; he had exfoliation of the bones of the 
cranium, and rupia, and was reduced to a most miserable state. 
Under our care the symptoms gradually disappeared ; he recovered 
to all appearance, and even got fat. He then caught cold, and 
relapsed again. At last his liver became engaged ; he was attacked 
with hypertrophy of the liver, ascites, and jaundice, and died soon 



HYPERTROPHY OF THE LIVER. 255 

afterwards. Here, then, we have venereal, abuse of naercury, 
periostitic inflammation, abuse of mercury followed by exacerbation 
of the periostitis, and the establishment of mercurial cachexy, and 
the history of the case is wound up with hypertrophy of the liver. 
This was the first case in which I had observed this concatenation 
of disease ; since that period I have seen a similar train of morbid 
phenomena, twice in private practice and once in hospital. First 
we have abuse of mercury, then periostitic inflammation and mercu- 
rial cachexy, and the scene is closed by morbid enlargement of the 
liver. Now I do not look upon this sequence as merely fortuitous. 
The diseased actions are, I think, related as cause and efl^ect, and 
each successive condition is consequent on the previous one. It 
may not be amiss to mention here some curious circumstances 
observed in the case to which I have just alluded. While this 
gentleman's liver was enlarging, there was no tenderness of the 
right hypochondrium on pressure. I have observed the same 
absence of tenderness in all the cases of this description which I 
have witnessed. The gentleman could bear pressure over the 
hepatic region without any inconvenience, and yet the liver was so 
enormously increased in size, that its inferior margin extended almost 
down to the pelvis. What is equally remarkable, he had no fever, 
and the tongue was perfectly clean and moist during the whole 
course of the hepatic affection. In my observations on a case in 
the fever ward, I remarked a few days since that some persons 
were too hasty in drawing inferences from the state of the tongue 
as to the existence of affections of the digestive organs. I shall not 
touch on this point, however, at present, and shall merely observe 
that this gentleman's tongpe was perfectly clean and moist, notwith- 
standing the morbid condition and rapid growth of the liver. 
Another curious circumstance was, that during the hepatic affec- 
tion, digestion appeared to go on very well, at least so far as the 
formation and due expulsion of fseces are concerned. The alvine 
evacuations were regular, and the matter discharged presented the 
form and consistence of that which is passed by a person in good, 
health. But there was a peculiarity in it to which my attention 
was first directed by the patient, who was an intelligent and ob- 
servant person. The cylinder of fsecal matter was composed of 
parts differing in colour and appearance; two or three inches con- 
sisted of pale clay-coloured substance; and immediately after this 
another portion of about the same length was observed, presenting 
the ordinary bilious or brown colour of natural excrement; and 
then again another mass of clay-coloured matter, without any ob- 
vious trace of bile. This appearance I have now frequently wit- 
nessed ; and the inference to be drawn from it is this — that in such 
forms of hepatic disease the functions of the liver are performed, as 
it were, intermittently; it secretes bile during a certain period of 
the digestive process, then stops, and then secretes again. 

This peculiarity is noticed in many diseases of the liver; and it 
is important to remark, in attempting to explain the rationale of 



256 GRAVES'S CLINICAL LECTURES. 

these hepatic affections, that in no disease of the liver is this symp- 
tom more frequently observed than in the scrofulous. Scrofulous 
disease of the liver is that state in which there is an increase of 
size in the organ, with induration and imperfect secretion, but with- 
out any remarkable tenderness. This condition in children is 
accompanied with irritability of the digestive organs, fretfulness, 
emaciation, loss of sleep, and impaired nutrition. The little patient 
becomes what is termed " pot-bellied," and labours under thirst, 
debility, and febrile excitement. This has been frequently called 
remittent fever, and disease of the mesenteric glands, but in my 
opinion unjustly. It is only a form of general cachexy connected 
with the scrofulous diathesis, affecting secretion and nutrition in 
general, and the digestive and biliary systems in particular. It 
would be quite wrong to imagine that, in this form of disease, the 
liver is the cause of the w^hole train of morbid phenomena : it is 
merely affected in common with other organs, and forms only an 
individual feature in the group of symptoms. 

Now in this form of scrofulous cachexy, where you have diar- 
rhoea, emaciation, fever, thirst, and restlessness, the liver is fre- 
quently affected in the manner already described ; and in the loose' 
stools of such a child you will find one part bilious, another part 
clay-coloured ; they will be yellow to-day, and pale the next, ac- 
cordingly as the Uver secretes bile or suspends its functions. But] 
in this instance, I repeat that the liver is only one of many oro^ans 
affected by the same general cachexy. Could we asceVtairT the^ 
derangements of other secreting organs with the same facility, it is 
very probable we should find similar evidences of the morbid 
influence which pervades the whole system. 

This view of the question shows that you are not to expect to 
succeed in removing the disease by the use of calomel or any other 
mercurial preparation. Many of those persons whose practice is 
little better than routine, when called to treat a case of this descrip- 
tion, first examine or inquire as to the nature of the alvine evacua- 
tions, and fixing on the single symptom of deficiency of bile, imme- 
diately prescribe calomel, to be repeated or continued until the] 
secret'ion of the liver is established ; but they forget that this state 
of the biliary system depends on the genera'l stafe of health, andj 
the absence of bile is the consequence, and not the cause of thel 
disease. Almost all the organs of the body are affected : and thoucrJii 
calomel may restore the secretion of the liver for a time, it cannotj 
bring back the organ to its natural state, or cure the disease. The' 
malad\' is to be remedied in a different way: the secretions (and! 
that of the liver among the rest) are to be improved by chanore of] 
air, by an appropriate diet, by exercise, tepid or cold bathing, and^ 
the use of those remedies which are adapted to modify or correct 
that state of the system on which the general derancrement depends. 

An observation of such cases has led me to a train of reflection 
respecting the occurrence of the same order of symptoms in per- 
sons who have been injured by the abuse of mercury. Many 



HYPERTROPHY OF THE LIVER. 257 

persons who get venereal employ naercury injudiciousk, and fall 
into what has been termed the mercurial cachexy, in Which there 
is a general unhealthy state of the organs. A patient who has 
fallen nito this slate very closely resembles a scrofulous person, and 
is apt to labour under the same emaciation, impaired nutrition, irri- 
tability, leverishness, and the same sort of cutaneous, glandular, and 
periostitic atiections. The chronic mercurial cachexy is very like 
the scrofulous, and attacks very nearly the same organs and tissues. 
Hence the dltiiculty of curing affections of the liver and other 
organs, when they are the result of this depraved habit. This is 
the key to the explanation of those horrible ravages which we fre- 
quently witness in cases of venereal disease complicated with mer- 
curial cachexy — a state of constitution which is closely allied to 
the scrofulous. You will frequently meet with this consecutive 
affection of the liver in cases of morbus coxse, where the patient 
has been labouring for years under ulceration of the joint. The 
growth of the rest of the body appears checked, the patient is 
stunted and emaciated, while the liver increases rapidly in size. It 
was frotn observing the occurrence of liver disease in the persons 
labouring under the scrofulous cachexy, that my attention was 
first turned to its occurrence in persons broken down by long or 
injudicious courses of mercury. 

One word as to the curability of hepatic affections of this kind. I 
beheve that it is always an unpromising form of disease ; but per- 
sons of originally good constitution, and under the age of thirty, 
will generally escape, if treated judiciously, and with proper care 
and attention. Some months ago I attended, with Dr. Marsh, a 
young gentleman labouring under this affection, as a consequence 
of the abuse of mercury. We found him greatly emaciated, and 
labouring under considerable enlargement of the liver, with com- 
mencing ascites. He had also great determination of blood to the 
abdomen, diarrhoea, and hemorrhoids. By strict attention to his 
bowels, a well regulated diet, change of air, and the use of taraxa- 
cum, conium, and hydriodate of potash, he was ultimately cLired, 
after an illness of nearly two years, during which the liver had 
grown to an enormous size. 1 may state that he is at present in 
gaod health, and that the liver is nearly reduced to its natural 
dimensions. It may be proper to add, that this gentleman's age is 
about four and twenty. 

I observed one circumstance in the progress of this case which is 
worth noting. He was suddenly attacked with a papular form of 
purpura, accompanied by much tingling and itchness, and answer- 
ing to the description given of 'purpura urticans. This peculiar 
eruption was very troublesome at night and formed several suc- 
cessive crops, which altogether lasted a month. It occupied the 
extremities upper and lower, and was very abundant on the latter. 
This gentleman wore a bandage to relieve a varicose state of the 
veins of the left leg. Now the eruption never appeared in the 

22* 



258 GRArES'S CLIXICAL LECTCEES, 

parts sDDJected lo the pressure of bandage,^ althongh it was very 
thick immediately below aod above those parts. 

In persons below thirty the Jiver may become enlarged to a very 
considerable extent, and yet return again to its natural size under 
proper treatment. I could point out several persons in Dubhn in 
whom the liver had been so much enlarged that I thought their 
cases hopeless, and yet they have recovered, and are at present in 
the enjoyment of good health. The process by which the organ 
returns to its natural state and dimensions is generally slow : in 
two or three cases it occupied a space of time varying from one to 
two years. I attended a gentleman some time ago with Mr. Carmi- 
chael ; and frora the histor}- of the case, as well as the s^'mptoms 
present, we were induced to look upon it as incurable ; and yet the 
patient has complete!}^ recovered. Mr. Macnamara and I attendee 
a lady who had a very remarkable enlargement of the liver, but in 
the course of the year the viscus diminished so much in size, as tc 
be very little above the normal dimensions. This is a matter of nc 
common interest, for cases of this description have been generally 
looked upon as be3'ond the reach of medical aid. You should 
therefore be very careful in your prognosis of such cases, and not 
give them up at once as incurable. 

I may observe, in conclusion, that it is entirely as the result of 

the cachectic habit that this enlargement of the liver is observed. I 

have assumicd this principle as the basis of ra'y argoioeol, and I 

think it is founded in fact and truth. It is also curioiK toobse:"e. 

that the same cachectic state which gives rise to emaciation ar.: : f- 

cay of the body, generally occasions hypertrophy of some parti: „ 

organs. What we most commonh" observe in such conditions 

general wasting of the system, accompanied by increased morb 

nutrition in certain organs. This appears to be the general la' 

You perceive that in the explanation I have given, I have 

that enlarged liver is the result of a general cachectic state of 

system, and it is of importance to recollect that this state may 

brought on by the injudicious exhibition of mercury, or by car. 

mercurialisation further than tije constitution will bear. In 

instance we are compelled lo allow that our practice may furn: 

weapons to be turned against us by the disciples of homceopa' 

It cannot however be denied, that the immoderate use of mere 

has been productive of liver disease. The late Mr. Hewson pointi 

out this to the attention of those who visited the Lock Hos|h: 

while under his care. At this period it was the custom to sah 

every patient, and keep him under the full mercurial influence 

a month or tw*o ; and it frequently happened that, just as the m- 

carial course was finished, the patient got disease and enlarg 

of the Hver. Were I inclined to iheonse, I might perhaps jo 

some fanciful hypothesis in explanation of this occurrence, 

might trace somie connection between the stimulant effects of m- 

cury on the liver, and the subsequent hypertrophy. I shall, ho 

ever, content myself at present with noticing the fact, and leave 



I 



ENLARGEMENT OF THE LIVER. 259 

the explanation to my juniors, who always explain nnatters, accord- 
ing to my observation, much more readily than their seniors. 

There are also other diseased states of the system, in which we 
have enlargement and morbid alteration of the liver. 1 can point 
out to you four different states of the system in which hypertrophy 
and disease of the liver forms one of the resuhs of the general affec- 
tion of the system. The next of those to which I shall direct your 
attention is scarlatina. Those who have attended the wards during 
the past month have seen examples of this. We have observed 
during the same week two patients labouring under scarlatina, who 
got disease of the liver and jaundice. One of the paiients, a little 
boy, was attacked with the disease in an extremely violent form, 
accompanied with high fever, and a very remarkable eruption. In 
a few hours after the exanthema appeared, the entire cutaneous 
surface was dyed of a brilliant red ; in fact, the skin looked as if it 
had been painted over, and there was not a single spot free. In 
cases of this kind the violence of the cutaneous inflammation is 
sufficient to kill, without any other unfavourable complication ; and 
the patient seldom lives more than three or four days. You 
observed in this case that the whole epidermis peeled off. But 
what I wish to direct your attention to is, that this boy after two 
days had evident symptoms of disease and enlargement of the liver. 
A young man, in the same ward, had also an attack of scarlatina, 
but in a milder form. On the third day he likewise got inflamma- 
tion of the liver, but was cured by general and local antiphlogistic 
treatment. You are aware that scarlatina is one of those diseases 
in which a train of unfavourable sequelae are apt to remain after 
the removal of the original complaint. Persons, after recovering 
from the exanthematous fever, will sometimes get into a bad state 
of health, and instead of convalescing, become restless and feverish 
towards evening — have an irritable jerking pulse, hot skin, derange- 
ment of the digestive organs, diminished urinary secretion, and 
finally become dropsical. Now, from observing the supervention 
of hepatic disease in such cases, both in hospital and private prac- 
tice, my attention has been directed to the liver; and I never omit 
making an examination of that organ when called to treat those 
symptoms which are looked upon as the sequelae of scarlatina. In 
many of these patients I have found the liver in the slate of inflam- 
mation of rather a chronic character, and without any of that 
remarkable pain or tenderness which characterises acute hepatitis. 
But still it was inflamed, as proved by the benefit derived from local 
antiphlogistic means; and, moreover, its condition appeared to retard 
and prevent convalescence. Not long since, a friend of mine, a 
very intelligent practitioner, who was attending a case of this de- 
scription, and had tried variety of remedies without any benefit, 
was very much surprised when I drew down the bed-clothes and 
showed him that the liver was diseased. He had not thought of 
the existence of anything like an hepatic affection, and was very 
much surprised that his treatment had proved so ineffectual. By 



260 GRAVES'S CLINICAL LECTURES. 

the use of leeches to the right hypochondrium, the employment of 
mercury, and a proper regulation of diet, the patient was soon re- 
lieved, and the fever, thirst, and anasarca, quickly disappeared. la 
cases of this kind the hepatic affection is the result of the general in- 
flammatory diathesis superinduced by scarlatina. You are all aware 
that nothing is more common, after scarlatina, than inflammation 
of various organs. Thus some persons are attacked with pleuritis, 
some with pneumonia, others with inflammation of the liver. Many 
persons continue in a valetudinary state after the eruption has de- 
clined ; they do not convalesce according to our expectations; the 
pulse remains rather quicker than natural ; the bowels are deranged; 
the appetite bad ; thirst urgent, and urine scanty. In many of these 
cases you will find that there is a species of chronic hepatitis going 
on, which keeps up the feverishness and retards convalescence. 
This is a point of great importance, to which I am the more anxious 
^to draw your attention, because even the latest writers on scarla- 
tina have either entirely omitted, or very insufficiently noticed it. 



LECTURE IT. 

Connection between disease of the liver and disease of the heart — Chronic hepatitis, 
from this source, curable in young persons — Enlargement of the spleen connected 
with superficial ulceration of the legs — Erysipelas and gangrene, sometimes of a 
pseudo-inflammatory character — Treatment of this form of disease. 

At my last lecture I endeavoured to point out some remarkable 
connections of diseased action observed in certain morbid states of 
the economy. I shall pursue the subject a little further to-day, as 
I look upon it as extremely important in a practical point of view. 
There is another organ Vvhose morbid aflfections frequently impli- 
cate the liver: I allude here to the heart. I have already spoken 
of certain cachectic states, in which the liver becomes enlarged and 
hypertrophied as the result of the general derangement of the sys- 
tem. In the present case the hypertrophy and disease of the liver 
originates in a morbid condition of the heart ; this is a very frequent 
cause of hepatic derangement. You have an example of it at pre- 
sent in the chronic ward, in the case of a poor man labouring under 
bronchitis of long standing, with disease of the heart, dropsy, and 
enlargement of the liver. In cases of this description, it is a matter 
of some difficulty to determine in what organ the morbid sequence 
commences; for where many diseases. co-exist, it is not easy to 
ascertain how they are related to each other as cause and effect. 
I have, however, had several opportunities of observing the progress 
of the disease from the commencement, and the manner in which 
the different organs become successively implicated. 

Some time ago there occurred a remarkable example of this form 
of hepatic affection in a relative of mine, aged fourteen, who, in 



CHRONIC HEPATITIS. 261 

consequence of exposure to cold, was attacked with rheumatic in- 
flammation of the joints, of a very intense character. Owing to a 
want of proper care, the disease was allowed to go on unchecked, 
and metastasis to the pericardium took place. I happened to be 
out of town at the time, and he had no advice or assistance for 
nearly twenty-four hours.. Pericarditis of a violent character be- 
came developed, and it was only by the most 'energetic treatment 
that he escaped with his life, jffe had pericarditis with effusion, 
and all the physical signs and symptoms of carditis. After the 
acute symptoms were removed, the signs of adhesion of the peri- 
cardium, hypertrophy, and partial valvular disease, continued ; and 
for a long lime the heart's action was invariably accompanied by a 
loud bruit de soufflet. These affections were followed by dyspnoea 
and increased action of the heart. But this was not all : he next 
got inflammation of the testicle, and finally chronic hepatitis with 
enlargement. The liver grew to a very considerable size ; it con- 
tinued to enlarge for about seven months; and, altogether, he 
laboured under a chronic form of hepatitis for more than a year. 
At last the disease yielded to treatment, and he recovered com- 
pletely. 

This, you will say, was a fortunate termination ; but in young 
persons the powers of nature often act in a very remarkable manner 
in remedying or removing disease, and cures are sometimes effected 
in such patients which it would be quite absurd to expect in per- 
sons advanced in life. After having laboured under a long train 
of diseases, and having continued an invalid for nearly five years, 
this young gentleman at last, owing to his youth and favourable 
constitution, surmounted all his maladies, and is at present as strong 
and healthy as any person I am acquainted with. In this instance 
the chronic hepatitis was the result of the pericarditis, which 
formed the first Hnk in the chain ; and for the space of a year this 
young gentleman continued to labour under an affection of the 
liver — the result of disease commencing in the heart. This is a 
morbid sequence very frequently observed. You have pericarditis 
accompanied with inflammation of the lining membrane of the 
heart, partial disease of the valves, hypertrophy of the muscular 
substance, and then enlargement and induration of the liver. This 
is a very common complication, and deserves your most particular 
attention. When you see a patient whose appearance indicates 
disease of the heart — who has swelling of the face, dyspnoea, livid- 
ity of the lips, and turgescence of the cutaneous vessels ; in fact, 
that peculiar expression of countenance which at once informs the 
practised observer that the patient is labouring under disease of the 
heart — you should not neglect to inquire after the condition of the 
liver, for in such cases it is very frequently in a state of chronic 
disease. I pointed out this circumstance some time since, in the 
case of a late surgeon, Mr. M., and directed the attention of the 
medical gentleman, engaged in the treatment of the case, to the 
liver, in which no one had suspected the existence of disease. 



CSAT]^^ 



iJ!xmrKE& 




CHRONIC HEPATITIS. 263 

gies. Besides, we have had a remarkable case of enlargement of 
the spleen in our wards at the same time we had the cases of hepatic 
disease to which I have alluded. I may observe that the circum- 
stances under which enlargement of the spleen takes place differ, 
in many points, from those which determine hypertrophy of the 
liver. We have but few examples of inflammation of the spleen, 
while the cases in which enlargement and congestion of that organ 
take place are numerous. From the peculiarities of its anatomical 
structure, the spleen is very apt to become suddenly enlarged. Like 
the liver, it may become indurated and hypertrophied from inter- 
mittent, or from some general disease afl^ecting the system, and thus 
lead to a train of secondary phenomena — the most remarkable of 
which is dropsy. But there is one peculiar symptom attending 
enlargement of the spleen, which I have frequently pointed out to 
the attention of the class, as observed at least in two-thirds of the 
cases, and of which we had an excellent specimen in the patient 
tinder treatment in the chronic ward. The history of this symptom 
is the more curious, as showing a remarkable uniformity in the 
phenomena of a particular disease at very distant periods of time. 
This is seen by comparing the most recent descriptions of Indian 
splenitis, as given in an able analysis of Voight's work on the 
Spleen, published in a late number of the British and Foreign 
Medical Review, and the description of enlargement and disease of 
the spleen given by Aretaeus. The ancients, it is true, cannot be 
now considered as authorities to be followed either in pathology or 
practice ; for they were ignorant of many of the most important 
facts connected with the healthy and diseased states of the human 
body. In consequence of their inaccurate anatomical notions, they 
were unable to appreciate or describe many of those details which 
now enrich the domain of pathological anatomy; their writings, 
however, are invaluable in many respects, as containing admirable 
descriptions of diseases which still continue to infest the human 
body, and as recording certain groups of symptoms which are still 
associated. A comparison of their descriptions with those of modern 
times cannot fail to be extremely curious, and may even prove 
highly instructive; for if we find that certain internal affections 
have, from the most remote antiquity up to the present period, been 
generally accompanied by peculiar derangements of distant parts, 
we are authorised in considering this connection to be something 
more than accidental, and consequently we may be led to discover 
relations between organs generally believed to be quite unconnected 
with each other. Thus, some years, I had three patients in suc- 
cession under my care, who laboured under chronic enlargement 
of the spleen, who were all afl^ected with a similar sort of cachexy, 
and had all the same affection of the skin — namely, superficial 
ulceration of the legs. This coincidence forcibly arrested my atten- 
tion ; and I was still more struck with the observation, on finding 
that Aret^us had noticed this very circumstance in his admirable 
description of splenitis. " If (says he) the spleen does not suppu- 



264 GRAVES'S CLINICAL LECTURES. 

rate, bat becomes chronically enlarged, then the patients lose their 
appetite, and become cachectic, swollen, and of an unnatural colour, 
while the surface of the body manifests a disposition to ulcerate, 
particularly on the legs; the ulcers are hollow, round, livid, sanious, 
and diiScuU to heal." This description agrees precisely with the 
cases to which I have already referred, and it coincides in a very 
remarkable manner with the acfcount lately given by Dr. Yoight, 
of chronic disease of the spleen, as it occurs in India. He observes, 
that the cachexy connected with the splenalgia Bengalensis fre- 
quently manifests itself by a tendency to ulceration ; the disposition 
to which is so great, that leech-bites ^d blisters occasionally give 
rise to foul or phagedenic ulcers, which, under certain circum- 
stances — as where the patient has used mercury, and is residing in 
a swampy district — will sometimes run on to a fatal termination. 
It is also curious, that the predisposing causes of the different varie- 
ties of chronic enlargement of the spleen, as given by Yoight, are 
exactly the same as those detailed by Aretasus; and both writers 
correspond in their statements as to the age and habits of life of 
persons most liable to this disease, as well as the nature of the 
locality and the season of the year most favourable to its produc- 
tion. This agreement between authors separated from each other 
by so many centuries, and who described the disease as it occurred 
in distinct regions and among different races of mankind, is ex- 
tremely curious, and exhibits a very remarkable example of the 
identity of the morbid phenomena produced by the same causes. 

So far of the pathological states of particular organs which arise 
in certain conditions of the system, and most generally form a ter- 
minating link in the chain of diseased action. You will perceive 
that mV observations are chiefly limited to a detail of the most 
important pathological observations made in our wards during the 
preceding three months. After we have made a brief review of 
what has occurred during in'is period, we shall take up the con- 
sideration of the cases at present under treatment. 

The next disease which came under our notice so often as to 
deserve a separate notice, was erysipelas. There were some points 
of interest connected with the history of the erysipelas which pre- 
vailed in this hospital during the months of August, September, 
and October. In the space of somewhat more than two months, 
we had abouttwenty cases of this disease; and, indeed, the morbific 
cause appears to be still lingering in our wards, thougii less fre- 
quently manifesting itself, for we have had only one case within 
the last ten days. Before, however, I proceed to notice the pheno- 
mena of the disease, as observed here, I shall make a few observa- 
tions connected with the treatment of this affection in general. I 
am anxious to direct your attention to this point, because the history 
of this epidemic has furnished some useful lessons, and has shown 
how much the treatment of any disease will depend on its epidemic 
character and existing peculiarities. The disease was treated here 
in every instance, and through all its stages, with wine, quinine, 



ERYSIPELAS. 265 

and opium ; and, with the exception of a single case, this treatment 
has proved uniformly successful. Erysipelas, you are aware, is 
generally looked upon as an inflammatory disease, and its treatment 
is always more or less antiphlogistic, particularly during the early 
stage. At this period it is customary to treat it with general bleed- 
ing, leeching, scarifications, purgatives, mercury, and tartar emetic ; 
and I will allow that many cases should be treated in this manner. 
But the gentlemen who have attended this hospital within the last 
three months have witnessed a form of erysipelas which required, 
from the beginning, an exactly opposite line of treatment. In the 
management of the cases which fell under our observation, no one 
in his senses would think of using general or local depletion, pur- 
gatives, or tartar emetic. The moment the disease appeared, we 
were obliged to attack it with tonics, narcotics, and stimulants. 
You perceive, then, that in erysipelas there are two very distinct 
extremes, between which there are many intermediate shades and 
varieties. It is well to bear this in mind. When you are called to 
treat a case of erysipelas, you should recollect that it is a disease 
capable of exhibiting a great variety of forms, amenable to no fixed 
line of treatment, and requiring for its management all the saga- 
city and skill of an accomplished practitioner. I have seen many 
instances in which this affection appeared in a distinct and well- 
naarked inflammatory form ; and I have treated cases with vene- 
section, leeching, purgatives, and tartar emetic, and found these 
means admirably well-fitted to remove the disease. Here, on the 
contrary, wine, opium, and sulphate of quinine, were the only 
remedies on which we could rely with any degree of confidence. 
On the other hand, you will meet with intermediate cases in which 
these different modes of practice should be employed, either at dis- 
tinct stages of the complaint and at a considerable interval, or should 
succeed each other by a rapid transition. Erysipelas, I must again 
repeat, should not be treated from its name. Many persons have 
maintained that, when gangrene supervenes on inflammatory affec- 
tions — and, among the rest, on erysipelas — it is the result of an 
excessive degree of inflammation, and that it might be successfully 
combated by judicious depletion. This, however, is by no means 
generally true ; and it is of importance that, in forming proper 
notions of the pathology and treatment of erysipelas, you should 
dismiss from your minds all preconceived opinions, and be regu- 
lated solely by the impressions derived from correct observation and 
facts. What I wish to impress upon your minds is, that gangrene 
may and does occur in cases of erysipelas quite independently of 
excessive inflammatory action, and requiring a plan of practice 
quite different from the antiphlogistic. I do not assert that gan- 
grene does not arise, in many instances, from the violence of 
erysipelatous inflammation, and that in such cases it is to be met by 
prompt and decided antiphlogistic treatment, but I think your views 
of the pathology of this disease will be both imperfect and false, if 
you look upon the gangrene which frequently supervenes in ery- 

23 



266 GRAVES'S CLINICAL LECTURES. 

sipelas as the result of immoderate inflammatory action. The 
following case, which is one of extreme interest, will, I think, bear 
me out in my assertion. 

Mrs. B., a lady of middle age, was attacked with feverish symp- 
toms on the 24th of last March. Notwithstanding the diligent 
employment of antiphlogistic treatment by Mr. Barker, the pyrexia 
increased ; in the course of a few days her throat became sore, and 
shortly afterwards erysipelas appeared on the face. Her case as- 
sumed a very dangerous aspect: she continued seriously ill for 
some days, and was saved with difficulty. On the 1st of April, Mr. 
Carmichael advised the diligent application of fomentations, with 
the view of relieving the local symptoms; and her son, a young 
man of eighteen, of temperate habits, florid complexiony muscular 
frame, and who had always enjoyed a vigorous state of health, 
undertook the duty of applying the fomentations with much zeal 
and assiduity. Towards evening, he thought, but without reason, 
that her case was hopeless, and fell into a violent paroxysm of grief, 
from which he was induced to rouse himself for the purpose of 
resuming his occupation of applying the fomentations. While thus 
engaged, he got, to use his own expression, " a whift' of sickening 
air from the bed-clothes," and immediately felt unwell. This was 
on the 1st of April. On the 2d, he was feverish and complained 
of headache, for which he got aperient medicine, and was leeched. 
On the 3d, there was no improvement, and he had passed the night 
without any sleep. On the 4th, Mr. Carmichael considered it 
necessary to leech the temples again, and to continue the exhibition 
of antiphlogistic and aperient medicines. He now began to com- 
plain of severe pain in the right shoulder, which at first appeared 
to be of a rheumatic nature. He became moTe and more restless, 
and on the 7th of April was reported to have slept none for the 
three preceding nights. A very perceptible fulness was. now ob- 
served under the right clavicle, extending down over the pectoral 
muscle; the parts were tender to the touch, but not red. Mr, 
Carmichael now examined the hand and arm of the same side with 
much attention, for the purpose of ascertaining whether any wound 
or injury had existed, for the symptoms seemed to resemble closely 
those produced by poisoned wounds. None, however, could be 
detected. The restlessness now increased to an extraordinary height; 
during the following night the patient changed from one bed to 
another at least one hundred times, and the servants were inces- 
santly employed in making and adjusting three beds, from one of 
which he wandered to another, impelled by an intolerable feeling 
of anxiety and uneasiness. During this period his bowels were 
free, his urine copious ; and though his fever was considerable, it 
was by no means proportioned to the nervous excitement, nor was 
it accompanied by delirium or pain in the head. The swollen parts 
of the trunk were leeched freely twice, and diligently fomented, 
and continued to present the same appearance until the 10th, when 
a red patch appeared near the shoulder, subsequently spreading into 



ERYSIPELAS. 267 

a vividly red erysipelatous blush, which occupied the skin covering 
the pectoral muscle and right axillary region. I saw him for the 
first time on the 11th. His pulse was 120, and by no means defi- 
cient in strength ; skin hot, but covered with perspiration ; he did 
not complain of headache, but was quite sleepless and excessively 
uneasy. His muscular strength was apparently not much reduced ; 
and, indeed, until a few hours before his death, he was able to turn 
in bed with ease. His tongue was dry in the centre, and furred, 
but moist at the edges. The erysipelas was now spreading rapidly 
towards the left side, and down the front of the abdomen. An 
attempt was made, but in vain, to arrest its progress by the appli- 
cation of nitrate of silver to the skin around its margin — an ope- 
ration which was performed with great care by Mr. Carmichael. 
Mercurial ointment was next applied to the inflamed surface; and> 
although the erysipelas continued to spread, we were led to enter- 
tain some hopes of our patient — having succeeded, by means of 
tartar emetic followed by opium, in procuring for him much, and, 
as he said, refreshing sleep. On the morning of the 13th, however^ 
a black colour of the corium was observed in the situation of one 
of the bullae on his left side. This alarmed us, and in a few hours 
afterwards our suspicions w^ere confirmed by the appearances of 
dark maculae in many parts of the erysipelatous surface. These 
livid patches spread very rapidly, and were in some places accom- 
panied by effusion beneath the cuticle, but in others they appeared 
to consist in a mere change of colour in the external surface of the 
erysipelatous corium, without any detachment of the epidermis. 
The patient took abundant nourishment, and got wine and cordials, 
but without any favourable efl^ect. The scrotum now became en- 
gaged, and speedily assumed a gangrenous appearance. In some 
places the epidermis separated, and the gangrenous surface of the 
corium secreted sanies in large quantity, but in many parts no 
detachment of the cuticle took place. On the 14lh, nearly the 
whole of the right side of the abdomen and the scrotum vi^ere 
superficially gangrenous, and the belly became tympanitic. During 
this time, apparently healthy faeces were discharged in considerable 
quantity; the skin was covered with perspiration; the urine was 
copious and natural ; and we had here, what is worthy of notice, 
apparently healthy secretions from the bowels, liver, skin, and kid- 
neys, co-existing with extensive gangrene of the surface. His 
tongue, however, continued dry and furred ; his restlessness una- 
bated; and the sleep previously procured by means of opium now 
ceased, although that medicine v/as repeated in the same doses. 
His pulse also began to sink, but he remained quite sensible and 
free from delirium until immediately before his death, which took 
place on the evening of the 15th. During the latter days of his 
illness, he had sweated copiously, and there was nothing remark- 
able in the odour of the perspiration. I may also observe that the 
pulse likewise furnished but very fallacious indications ; for I can 
assert, with truth, that six hours before his death, though soft and 



268 GRAVES'S CLINICAL LECTURES. 

compressible, it still possessed a steadiness and a volume by no 
means calculated to impart a suspicion of his approaching dissolu- 
tion. His strength was also such as would lead to an erroneous 
conception of his real danger; for, as I have before observed, he 
was able to turn in bed shortly before death. This observation is 
borne out by other cases, in which persons with extensive gangre- 
nous erysipelas, and in imminent danger, have been known to be 
capable of walking about. 

The evidently contagious nature of the erysipelas in this instance, 
and the youth and previously good health of the patient, render this 
case sufficiently remarkable. It is likewise worthy of notice, as 
proved by the circumstances, that the gangrene did not originate 
in the excessive violence of the cutaneous inflammation ; for it did 
not appear in those portions of the skin which were primarily and 
most violently affected. On the contrary, we observed that the 
parts which became gangrenous had been paler and less tense than 
those which did not assume that condition, and that the portions of 
the skin which died were those which had become engaged at the 
latter stage of the disease. This is of importance ; for, combined 
with other facts, it forms an obvious refutation of the opinion not 
long since maintained, that gangrene and sphacelus are in all in- 
flammations the result of immoderate inflammatory action, and 
consequently to be averted by antiphlogistic treatment only. In 
many instances this opinion, and the treatment founded on it, are, 
no doubt, judicious ; but that there are cases in which the gan- 
grenous tendency supervenes on inflammation — or,in other words, 
is superadded to the inflammatory process, but independent of its 
intensity — no one will deny who candidly weighs the details of the 
case which I have just related, and recollects that the conclusions 
deducible from them have of late received too frequent a confirma- 
tion, from the rapidly fatal progress of putrid sore throat — a form 
of cynanche which has reappeared in Ireland, after having almost 
disappeared for upwards of twenty years. In both cases the disease 
appears to be infectious, and in both the gangrene seems to be quite 
independent of the intensity of the inflammation. 

This is a question so important, in a practical point of view, that 
I shall make no apology for detaining you, as I am anxious to im- 
press upon the minds of my younger auditors that there are certain 
forms of disease, termed inflammatory, in which the ordinary treat- 
ment by depletion is quite inadmissible. I shall, at my next Lecture, 
enter upon the treatment of fever, and endeavour to communicate 
such observations as a review of our cases for the last three months 
has aflfbrded. And here I beg leave to return my thanks to the 
gentlemen who have furnished the cases, and to express the grati- 
fication I have felt in finding that so many of the pupils have 
recorded their facts in such a clear and satisfactory manner. 



ERYSIPELAS. 269 



LECTURE III. 

Erysipelas in an epidemic form — Symmetrical spread of erysipelas on the body — 
Maculated fever, and Irish typhus — Dr. Lombard's remarks — Improved treatment 
of fever — Choice of a proper nurse and assistants — Air of the sick chamber — 
Necessity of attending to diet and nourishment. 

I SHALL now resume the subject of erysipelas, which I alluded to 
in a cursory manner at our last meeting. You will recollect^I 
mentioned that we had a kind of epidemic erysipelas in our fever 
wards during the months of August, September, and October; this 
has now almost disappeared, for we have had but one case during 
the present month. The disease generally attacked the head, com- 
mencing in the scalp, or about the nose and cheeks ; but in some 
cases it appeared first on the nape of the neck, particularly in those 
patients who had been blistered in that situation during the course 
of fever. The fever which now prevails seldom abates in less than 
fourteen or seventeen days; and it was generally about the termi- 
nation of the febrile excitement, and while convalescence was going 
on, that the erysipelas appeared. Usually, on the fourth or fifth 
day of convalescence, a change was observed in the patient, and 
the erysipelatous attack commenced, being ushered in by a feeling 
of weakness and uneasiness, or an indistinct rigor, followed by 
quick pulse, headache, some increase of thirst, and in most cases 
by a marked change in the tongue, which became dry and parched. 
The inflammation was of a superficial character, expending itself 
almost exclusively on the external surface of the corium, and not 
affecting to any extent the subcutaneous cellular tissue. 

You are aware that erysipelas becomes obstinate, complicated, 
and dangerous, in proportion as the inflammation spreads inwards. 
In such cases its characters are less distinctly marked, audit makes 
a near approach to a very formidable disease — diflfuse inflamma- 
tion of the cellular substance. The affection of which I am now 
speaking was generally simple, and in most cases limited to the 
superficial apparatus of the corium. It was characterised by the 
ordinary phenomena of true erysipelas, namely, redness, heat, a 
burning sensation, and slight elevation of the aflfected parts. There 
was seldom any remarkable degree of oedema, except in some cases 
where it attacked the eyelids ; and we had no instance of abscesses 
forming under the skin. It was attended with a considerable de- 
gree of constitutional disturbance, and the fever generally continued 
for four or five days. On looking over the cases of this affection, 
which have been recorded by the gentlemen who had charge of the 
patients, I find that in most instances the fever terminated on the 
sixth day. In many cases a peculiarity was observed, to which I 
have alluded on a former occasion, namely, the spread of the ery- 
sipelatous redness in a perfectlv symmetrical manner. I believe I 

"23* 



270 GRAVES'S CLINICAL LECTUKES. 

was the first who directed attention to the fact, that when erysipe- 
las commences at any point of the mesial line of the body, it is very 
apt to spread in a symmelrical manner. Thus, in the present in- 
stance, the inflammation commenced in the majority of cases about 
the nose, and then extended in a perfectly symmetrical manner over 
the forehead and down the neck ; or when it appeared first on the 
nape of the neck, it travelled dov;n between the shoulders with a 
very remarkable symmetry of extent and outline. Sometimes this 
precise correspondence did not exist ; but I can assert that in more 
than two-thirds of the cases it was extremely well marked. It ap- 
pears, then, that this occurrence is not so very rare as my friend 
Dr. Johnson supposes. When I first noticed the fact of the occa- 
sionally symmetrical spread of erysipelas, he said it was an ob- 
servation of very little importance, and that it was to be looked 
upon as a matter of mere curiosity, a phenomenon which a man 
would not see twice in the course of his life. I have, however, 
shown it to many of the students half-a-dozen times during the last 
two months. 

The treatment of this afl^ection, which was abundantly simple, 
and the same in every instance, was entirely regulated by the cir- 
cumstances under which the erysipelatous attack occurred. No 
local treatment was employed, nor was any required. It was not 
necessary to apply leeches, cold lotions, fomentations, or mercurial 
ointments. The cutaneous inflammation was not either very ex- 
tensive or intense ; and the constitutions of the patients did not 
admit of any kind of depletion. The internal treatment was de- 
termined on, more from a consideration of the circumstances under 
which the disease had appeared, than from an accurate analysis of 
the symptoms, or from any preconceived opinions of the nature of 
the complaint. In the practice of your profession you will be fre- 
quently called upon to treat affections, in which you will have to 
consider not only the existing symptoms, but also the circumstances 
under which they have originated ; and in many instances you will 
find that your treatment will be determined more by the latter than 
the former. Here we had a number of patients labouring under 
erysipelas, at a period when the system was reduced by fever, and 
the powers of life at a very low ebb. No one could think of using 
antiphlogistic or depletory measures under such circumstances. 
Recollecting that our patients had just emerged from a dangerous 
disease, we adopted a very different mode of treatment; and in all 
cases, except where the patient's strength was unbroken, the fever 
high, and the local symptoms of an intense character, we had re- 
course at once to tonics, narcotics, and stimulants. We first gave 
an emollient injection, and then administered sulphate of quinine 
in the form of enema, to the amount of from five to ten grains, 
blended with mucilage of starch. This was administered twice a 
day, and the patient was directed to take small quantities of wine 
and light nourishment. 

Many of the pupils at the time were surprised at this mode of 



FEVER. 271 

treatment. From the dry state of the tongue, the occasional de- 
lirium, the restlessness, and the headache present, they were in- 
clined to think that the patients would be injured rather than served, 
by dietetic and medicinal stimulants of this description. I had, 
however, witnessed cases of a similar description, and had observed 
the tongue become clean and moist, the skin soft and cool, the 
thirst, fever and restlessness subside, and the local symptoms dis- 
appear under the use of wine. In this instance, also the value of 
our mode of treatment was borne out by the result ; for, with the 
exception of a single case, all our patients recovered. In one in- 
stance the disease assumed a malignant form, and carried off the 
patient in a few hours. She was a young girl of apparently 
vigorous constitution, and who had got tolerably well through a 
dangerous maculated fever: towards the middle of the fever she 
had exhibited symptoms of cerebral excitement, for which we 
deemed it necessary to blister the scalp. At the time when the 
erysipelatous attack came on, she had been for several days ill, and 
was in that low state in which the skin h^s a great tendency to be- 
come ecchymosed, and form bad sores. This tendency I have ob- 
served in many instances of low fever, and it is a condition which 
is always pregnant with danger. The occurrence of ecchymosis, 
excoriation, and superficial gangrene, in such cases, is not so much 
the result of pressure, as of the general debility, and the impaired 
condition of the fluids and solids of the body. It was in this state 
of the system, and with her scalp still suffering under the inflam- 
mation produced by the blister, that this poor girl was attacked with 
erysipelas of the face. Unfortunately, at the time the erysipelas 
attacked the sound skin of the head, the blistered surface was at- 
tacked with gangrene ; and two dangerous local affections became 
thus suddenly conjoined. Under this unfavourable complication 
her constitution sank with great rapidity, and she died in twenty- 
four hours from the commencement of the attack. 

I shall now, in pursuance of my intention, proceed to speak of 
the treatment of fever. I may observe here, that we are now at a 
point of time possessing no common interest for the reflection of 
medical observers. It is now nearly two years since my attention 
"was first arrested by the appearance of maculated fever, of which 
the first examples were observed in some hospital patients from the 
neighbourhood of Kingstown. This form of fever has lasted ever 
since, prevailing universally, as it had banished all other forms 
of fever, and being almost the only type noticed in our wards. 
Within the last four days, however, a change appears to have taken 
place. Scarcely any cases of maculated fever have been admitted 
within the last fortnight, and the majority of fever patients at pre- 
sent under treatment are free from the cutaneous eruption so fre- 
quently observed during the last two years. The cases which we 
have recently admitted present no spots, or maculae, and have been 
termed, perhaps improperly, simple typhoid fever. And here per- 
mit me to observe, that it would be very wrong to conclude, from 



272 GRAVES'S CLINICAL LECTURES. 

this circumstance, that our recent cases are of a more favourable 
description than those which preceded them ; the disease, it is true, 
appears to have lost a character which is always looked upon as 
bad and unfavourable, but it may be just as dangerous a modifica- 
tion of fever as the eruptive typhus. During the predominance of 
the latter form, all cases without maculse were in general simple 
and free from danger ; but it is probable that this is not the case at 
present. There are two cases of this non-macuhited typhus in the 
female ward, which are of an extremely doubtful character, and in 
which it would be difficult to predict the result. Indeed, were I to 
make any prognosis, I should say that the chances, if not against 
them, are at least very fairly balanced. 

Now, gentlemen, as it appears we have come to a change, and 
that we may have to treat a new modification of fever, it behoves 
us to be extremely vigilant. I invite you to watch and study, with 
the closest attention, the cases of fever which come before you. 
Let us, in the first place, endeavour to ascertain whether we have 
seen the close of one epidemic, and are now at the commencement 
of another. The number of cases of simple typhoid fever have, 
you perceive, increased in a very remarkable manner, and the 
number of cases of eruptive typhus have become remarkably scarce. 
But there is another and a more important reason why we should 
study these cases with all due diligence and attention. They may 
be the first examples of a new epidemic, and every new epidemic, 
as it has its peculiar characters, so has it its peculiar treatment. 
We cannot follow the same track which we have pursued for the 
last two years — we cannot apply our remedies with the confidence 
of experience — we must now strike into a new path, and for some 
time our practice must be tentative and experimental. It was only 
after a good deal of experimental observation that we were able to 
arrive at a plan of treatment adapted to meet the exigencies of the 
maculated form of fever ; and it is very probable that this new fever 
may prove at first extremely difficult to manage ; and it may be 
some time before the diminished rate of mortality will show that 
we have at length discovered its true character, and the remedies 
best calculated to arrest its progress.* 

Let me now direct your attention to some practical points con- 
nected with the treatment of the maculated fever which has pre- 
vailed for the last two years, and which has spread to a very con- 
siderable extent in this city and its environs, attacking alike the 
upper, middle, and lower classes of society. It is not my intention 
to enter into a detailed history of the origin and progress of this 
fever, its varieties, symptoms, and pathological phenomena ; my 
purpose is to furnish you with a brief but comprehensive outline of 
its treatment, and of the remedies which have been found most 
successful in its removal, as well as the most appropriate time and 

* Since this lecture was delivered, many cases of typhus without maculae 
have been admitted, but the maculated form of fever still continues very 
com men. 



FEVER. 273 

mode of their application. But as many of the students are un- 
acquainted with this form of fever, I shall premise by observing 
that it is the same fever which has been frequently observed in this 
country, and of which a full account has been given in the Report 
published by Dr. Cheyne and Dr. Barker. You will also find a 
sketch of its principal characters in one of my lectures, published 
in the 172d No. of the London Medical and Surgical Journal for 
May, 1835. It is generally insidious in its first attack, and the 
symptoms are by no means proportioned to the subsequent danger. 
From the third or fourth to the seventh day, generally about the 
latter period, an eruption of dark-red spots appears on the skin in 
various parts of the body. Towards the latter stage, this fever is 
characterised by great nervous derangement, either with or without 
symptoms of cerebral congestion. It rarely lasts less than fourteen 
or seventeen days, and very seldom terminates by a well-defined 
crisis. It has spread extensively through this country, and has 
been observed at Liverpool, Glasgow, Birmingham, Manchester, 
Edinburgh, and London. In this country it has been for many 
years the prevailing type, and, although its spread as an epidemic 
may have been checked, and its course interrupted, by the occur- 
rence of other diseases, it is always found in this country, and pre- 
vails in a distinct form. It may originate spontaneously, or from 
contagion. From what I have seen of it, I have no doubt of its 
double origin. I am also inclined to think that it never attacks the 
same individual more than once, and that when a man has had the 
true maculated fever, he never gets it again. In this point, as well 
as in the eruption, it bears a close analogy to the exanthemata. It 
is so much more common in Ireland than in any other country of 
Europe, that my friend, Dr. Lombard, of Geneva, calls it the Irish 
typhus. Whether it be from the moisture of our climate, or from 
the poverty and wretchedness of the people, I know not ; but it is 
a fact that typhus is more prevalent in this country than in any 
other European nation. This may be easily seen by comparing 
the proportion of fever patients treated in the hospitals of the 
various capital cities, with the number treated in the same way in 
Dublin. Dr. Lombard also states, that the British towns which 
have most intercourse with this country, have more of this fever 
than those which are more remote, or have less intercourse with 
us. Thus there is more maculated fever seen in Liverpool and 
Glasgow, than in Edinburgh, Birmingham, or London. He looks 
upon it as a fever peculiarly Irish, originating in this country as 
an endemic, from causes the nature of which are not well under- 
stood : and that when it appears in English or Scottish towns, it is 
the result of contagion imported from Ireland. You will find some 
very interesting obvervations on this subject in his papers, published 
in the 26th number of the Dublin Medical Journal. 

In the fever of which I speak, there is nothing which would lead 
to the conclusion that the disease arose from inflammation. Many 
persons have regarded fever as produced by inflammatory affections 



274 GRAVES'S CLINICAL LECTURES. 

of some organ or system of the body, and have asserted that it is in 
every instance preceded and accompanied by some form of local in- 
flammation. One class of pathologists have placed the seat of this 
inflammation in the brain, another and a more numerous class in 
the digestive system : and all have believed that inflammatory action, 
whether limited to one or more organs, is the cause of fever. No 
opinion can be more unfounded, so far as typhus is concerned. 
Local congestion and inflammations may and do frequently arise 
in fever, but they are merely superadded to it, and form no part of 
its essence. I have now witnessed many cases in which fever ran 
through its course to a fatal termination without any distinct evi- 
dence of local inflammation or even congestion ; and I have 
dissected numerous cases, of fever in which there was not any ap- 
preciable trace of inflammatory action in the organs of the three 
great cavities. 

Having made these general observations, I may observe, in addi- 
tion, that in the whole range of human maladies there is no disease 
of such surpassing interest and importance as fever ; and I cannot 
dwell too much on the necessity of your applying most attentively 
to the study of its pathology and treatment. If you compare the 
mortality from fever with that resulting from any other disease in 
this country, you will be struck with the overwhelming fatality of 
this affection, and will readily admit the inestimable value of a 
thorough knowledge of its nature and treatment. Recollect, too, 
that fever is a disease which numbers among its victims persons 
chiefly in the prime of life, and during the most active and useful 
stage of existence, — fathers and mothers, persons who are the orna- 
ment or the stay and support of their families, the intellectual, the 
industrious, the efficient, — those whose lives are most valuable to 
their friends and to society. This gives an additional interest to 
the study of fever, and should stimulate you to endeavour to arrive 
at a correct knowledge of its nature and treatment. And here let 
me observe, that there is nothing more untrue than the assertion, 
that the treatment of fever is a matter of indifference. It has been 
the custom to look upon every plan of treating fever as idle and 
absurd, and until very lately there were many persons in this 
country who believed that patients recovered, not from having had 
the advantage of treatment, but from goodness of constitution or 
some favourable accident ; and it was usual with such persons to 
appeal to the experience of Dr. Rutty, who, in recording the history 
of the epidemics of his own time, observes, that the mortality was 
greatest among those who were best attended to, and that those 
who were left to God's providence, and got nothing but cold water, 
recovered. And, indeed, I must admit that the treatment of some 
of the cases of fever w^hich I witnessed when a student, would 
seem to justify the quaint and sarcastic observation of Dr. Rutty* 
At that period, whether it was from bad treatment, or from what 
has been termed the ni?nia diligentia medici, it is a fact that the 
maximum of mortality was among the rich, and that those who 



FEVER. 275 

"were most attended to died most speedily. In the epidemics of 
1816, 1817, 1818, and 1819, it was found by accurate computa- 
tion, that the rate of mortaUty was much higher among the rich 
than among the poor.* This was a startling fact, and a thousand 
different explanations of it were given at the time ; but I am in- 
clined to think that the true explanation was, that the poor did not 
get so much medicine, and that in them the vis medicatrix had 
more fair play. I could appeal to the practice of those times in 
proof of this opinion, and as we go along I shall have an opportu- 
nity of alluding to this part of the subject again, and contrasting 
the practice of the present day with that which was generally 
followed thirty years ago. If you look to Dr. Cheyne and Dr. 
Barker's Synopsis of the plan of treatment employed by the physi- 
cians of those days, you will be prepared, from a mere inspection 
of it, to admit, that it was at least as hard to escape the physician 
as the disease. Since that period our practice has greatly im- 
proved, and things are much changed ; the preponderance of fatal 
cases is now to be found among the poor, and the mortality among 
the rich, or those who have proper medical advice from the com- 
mencement, is not one-third of that which is found among the in- 
digent, who are generally neglected at the commencement of the 
disease. I am therefore fully prepared to deny that, in the present 
state of medical knowledge, our practice is a matter of indifference ; 
on the contrary, there is no disease in which diligent attention and 
skilful treatment are more frequently successful than in fever, nor 
is there any affection of equal importance in which our therapeutic 
means are more efficient and valuable. 

Now, when called on to treat a case of fever, there are several 
things which require your attention. In the first place, you should 
examine the state of the family arrangements. This is a matter 
which men are apt to overlook or treat as a matter of indifference, 
but in my mind it is of no ordinary importance, and should always 
be attended to. You should never, if possible, undertake the treat- 
ment of a case of fever where the friends or relations of the patient 
supply the place of a regular fever nurse. The mistaken tender- 
ness of relatives, and their want of due firmness, presence of mind, 
and experience, will frequently counteract your exertions and mar 
your best efforts. Affection and sorrow cloud the judgment, and 
hence it is that very few medical men ever undertake the treatment 
of dangerous illness in the members of their own families. The 
sympathy which a nurse should have for her patient should be 
grounded on a general anxiety to serve, and a strict sense of duty, 
as well as a laudable desire of increasing her own reputation; it 

* [It is true that in ordinary cases of typhus the treatment must be extremely 
simple ; the mildest measures which do not disturb the course of the fever, but 
merely aid the curative powers of nature by removing the symptoms which are 
unusually severe, are the best. Any violent disturbing means are positively 
mischievous. This is nothing but the expression of a general law, which is 
■applicable to all continued fevers attended with a cutaneous exanthema. — Ed,'\ 



276 GRAVES'S CLINICAL LECTURES. 

is, in fact, a sympathy analogous to that which a physician should 
have. Again, it will not do to have a nurse who has been usually 
employed in other diseases ; your assistant must be a regular fever 
nurse, and the man, who undertakes the treatment of a long and 
dangerous case of fever without such an assistant, will often have 
cause to regret. I could mention to you many cases illustrative of 
the truth of this assertion. I could tell you, that where I have per- 
mitted the continuance of the services of one of the family, or of a 
common nurse, I have been almost invariably annoyed and disap- 
pointed. I now make it a general rule to refuse attending any dan- 
gerous and protracted case of fever without a properly qualified 
nurse. 

In the next place, when treating a case of bad typhus, do not 
think that it will be sufficient to see your patient once a day. But 
you will say, perhaps, that our hospital patients here do very well, 
and yet they are visited only once in the twenty-four hours. True 
« — but then we have experienced nurses to look after them at all 
hours ; we have the valuable surveillance of our apothecary, Mr. 
Parr ; we have the attendance of the resident pupils, and of the 
gentlemen who take charge of the cases. You see, then, that they 
do not depend on a solitary visit. How often has Mr. Parr, the 
resident pupil, found it necessary to change the treatment adopted 
at the morning visit? How often have the remedies of which we 
had only given a hint in the morning, been actually and energetic- 
ally employed before the close of the day; and how often have 
lives been saved by the valuable attentions to which I have just 
alluded ? No one should attend a case of fever without having 
proper medical assistants. My practice, in general, is to visit my 
fever patients two or three times a day; and, when I have a bad or 
a dangerous case to manage, I always have a competent medical 
assistant to stay by the patient and watch every change of his 
malady. I do not know how they manage this matter elsewhere, 
but in this city we have so many zealous intelligent students, so 
many young medical friends, and so many well-educated apothe- 
caries, that we are never at a loss for an assistant. This fact is, I 
think, a sufficient answer to the objections put forward by Dr. 
Johnson, in the last number of the Medico-Chirurgical Review. 
*He says that tartar emetic is a two-edged sword — an agent power- 
ful alike for good or evil, and in the administration of which no 
ordinary circumspection is demanded. All this I am willing to 
admit ; there is no remedy capable of producing more mischief 
when abused, but when properly w^atched it is, I am confident, the 
means of saving many valuable lives. He says, also, that Dr. 
Graves cannot give that share of attention to his patients which 
the employment of such a remedy demands. He is quite mistaken 
on this point. I am never at a loss for some skilful person to re- 
main with the patient, watch the operation of each dose, and modify 
or change it according to circumstances. The want of proper 



FEVER. 277 

assistants may be an objection to the administration of tartar emetic, 
but this objection does not hold good with respect to DubHn. 

One or two more observations of a general nature. Some per- 
sons have such a terror of foul air, in cases of fever, that you will 
find all the windows in the house thrown open, not even excepting 
those of the patient's bed-chamber, and wherever you turn you are 
sure to meet with a current of air. Now, this is an unnecessary 
practice, likely to entail disease on the family and local inflamma- 
tion on the patient. The bed-room of a patient labouring under 
fever should be well aired, but without what is termed thorough 
air; and it should, if possible, be a quiet back room, away from 
the street. In the next place, it should be sufficiently large to hold 
two bedsteads conveniently ; and you should order the attendants 
to have two w^eli-aired beds in readiness, from one of which the 
patient should be changed to the other every twelve or twenty-four 
hours. You can scarcely have an idea of the comfort this affords 
to a person in fever. The room can be kept properly ventilated by 
a fire, and the temperature can be regulated by a thermometer. 
Some persons are in the habit of constantly sprinkling the room 
with vinegar — others with the chlorides. I do not know that it is 
necessary, and I think the use of chlorine is doubtful, if not im- 
proper, and may prove injurious to the patient. 

Having made these few general observations on the steps to be 
taken by those who enter on the treatment of typhus, I shall now 
proceed to speak of diet and medicines. In a disease like fever, 
which lasts frequently for fourteen, twenty-one, or more days, the 
consideration of diet and nutriment is a matter of importance, and 
I am persuaded that this is a point on which much error has pre- 
vailed. I am convinced that the starving system has, in many 
instances, been carried to a dangerous excess, and that many per- 
sons have fallen victims to prolonged abstinence in fever. This 
was one of the errors which sprung from the doctrines of those 
who maintained that fever depended on general or topical inflam- 
mation. They supposed that fever arose from inflammation, and 
immediately concluded that, to treat it successfully, it was necessary 
to reduce the system by depletion and lov/ diet, and to keep it at 
this point during the whole course of the disease. Hence the strict 
regimen — the diUe ahsolue — of the disciples of the physiological 
school, and of those who looked on inflammation as the essence of 
fever. The more the symptoms appeared indicative of inflamma- 
tory action, the more rigorous was the abstinence enforced. If a 
patient's face was flushed, or his eyes sufl^used, no matter what the 
stage of the fever was, they said, " here is inflammation of the 
brain, and nourishment will exasperate it.'^ If he had red or dry 
tongue, and abdominal tenderness, they immediately inferred the 
existence of gastro-enteritis, and all kinds of food, even the lightest, 
were strictly forbidden. That this proceeds from false notions on 
the nature of fever is beyond doubt, and I pointed out this fact 
many years ago, long before the appearance of Piorry's work. Let 

24 



278 GKAVES'S CLINICAL LECTURES. 

U3, in the first place, examine the results of protracted abstinence 

in the healthy stale of the system. Take a healthy person and 
deprive him of food, and what is the consequence ? First, hunger, 
which after some lime goes av,-ay, and then returns again. After 
two or three days, the sensation assumes a morbid character, and, 
instead of being a simple feeling of want and a desire for food, it 
becomes a disordered craving, attended with dragging pain in the 
stomach, burning thirst, and some time afterwards epigastric ten- 
derness, fever, and delirium. Here we have the supervention of 
gastric disease, and inflammation of the brain, as the results of pro- 
tracted starvation. Now, these are in themselves very singular 
facts, and well deserving of being held in memory. Read the ac- 
counts of those who perished from starvation after the wreck of the 
Medusa and the Alceste. and you will be struck with the horrible 
consequences of protracted hunger. You w^ll find that most of the 
unhappy sufferers were raging maniacs, and exhibited symptoms of 
violent cerebral irritation. Now, in a patient labouring under the 
effects of fever and protracted abstinence — whose sensibilities are 
blunted, and whose functions are deranged — it is not at all impro- 
bable that such a person, perhaps also suffering from dehrium or 
stupor, will not call for food, though requiring it : and that if you 
do not press it on him, and give it as medicine, symptoms like those 
which arise from starvation in the healthy subject may supervene, 
and you may have gastro-enteric inflammation, or cerebral disease, 
as the consequence of protracted abstinence. You may, perhaps, 
think that it is unnecessary to give food, as the patient appears to 
have no appetite, and does not care for it. You might as well 
think of allowing the urine to accumulate in the bladder, because 
the patient feels no desire to pass it. You are called on to interfere 
where the sensibility' is impaired, and the natural appetite is dor- 
mant : and you are not to permit your patient to encounter the 
horrible consequences of inanition, because he does not ask for 
nutriment. I never do so. After the third or fourth day of fever, 
I always prescribe mild nourishment, and this is steadily and perse- 
veringly continued through the whole course of the disease. 



i 



LECTURE IV. 

General treatment of fever — Dietetic management — The gtarration system mav pro- 
duce organic disease — Proper food for fever patients and coDvalescents — AllaTing 
of thirst — SedatiTes — Expergefacients — Efficacy of green tea in a case of nar- 
cotism — Flagellation effectual in a case of poisoning with opium. 

At my last lecture I spoke of some preparatory steps which 
should be taken before you enter on the treatment of a case of fever. 
I stated that one of the most essential requisites was a good nurse; 
that you can readily find persons to undertake this office in every 
family, but that it is rare to meet with any individual among the 



TREATMENT OF FEVER. 279 

patient's relatives properly qualified to discharge so important a 
duty. There is a vast difference between readiness to undertake 
and abihty to perform. Some persons are always adoing, but never 
do right; always attempting, but never successful. There are 
many nurses who are extremely attentive, but inexpert and injudi- 
cious, and their ill-judged attentions are frequently prejudicial to 
the patient. A fever nurse has a vast deal in her power; if an 
enema is to be administered, the patient will be much less disturbed 
and annoyed than if it were given by an unskilful person. The 
mere handling of a patient — the moving of him from one bed to 
another — the simple act of giving him medicine or drink — the 
changing of his sheets and linen — the dressing of his blisters — and 
a thousand other offices, can be performed with advantage only by 
an experienced nurse. Always bear in mind that it is of the 
utmost importance to economise the patient's strength in fever. The 
very act of lifting him up, or moving him from one side to another, 
tends to produce exhaustion. In the advanced stages of fever, the 
services of a properly qualified nurse are inestimable. Then there 
is the moral management of the patient, and this is an office which 
no one can undertake unless qualified by experience, and a correct 
knowledge of the habits of persons labouring under such forms of 
disease. Every one admits the value of moral superintendence in 
the treatment of the insane. Now there are very few patients who 
are not in a state analogous to insanity, for a longer or shorter 
period, during a course of typhus fever. There is a necessity for 
moral management in fever as well as in insanity, and this is un- 
derstood only by an experienced nurse. Friends and relatives are 
seldom found capable of discharging this office. If they chance to 
discover from the physician's remarks, or questions, the weak points 
of the patient's case, they generally contrive to let him know them 
in some way or other. If the patient is restless, for instance, the 
ill-judged anxiety of his friends will most certainl}^ prevent him 
from sleeping. They steal softly to his bed, draw the curtains, 
move the candle so as to make the light fall on his eyes, and wake 
him perhaps at the moment he is settling down to rest. If he hap- 
pens to take an opiate, and that they are aware of the nature of his 
medicine, they inform him of it, and his anxiety for sleep, conjoined 
with their inquiries, prevent its due operation. Hence, when you 
prescribe an opiate, you should nut, in many cases, say anything 
about it; and it should not be administered in such a way as to 
lead the patient or his friends to expect any decided benefit from it. 
It is only where I have to deal with prudent persons that I break 
through my rule of concealing both the nature of the medicine and 
the results which I expect from its operation. One of the best 
ways of giving an opiate is to administer it in the form of an enema. 
The patient's attention is then turned away from the consideration 
of loss of rest — he supposes that the enema is to act on his bowels, 
and in expecting a motion he drops asleep. You will, often, too, 
succeed in producing sleep in this way, where you would fail in 



280 GRAVES'S CLINICAL LECTURES. 

bringing it on by an opiate administered by the mouth. Another 
recommendation attached to this mode of exhibiting opiates is, that 
it can be employed in cases of delirium, where the patient obsti- 
nately refuses to swallow any kind of medicine. Let me give you 
here another caution. Do not let the patient know the situation or 
extent of his danger, however you may feel hound to act in refer- 
ence to these matters towards his relatives or friends. If you 
apprehend mischief in the brain, do not commence by examining 
the head, or putting your questions in such a manner as to lead 
him to suspect the seat and nature of the affection. The same 
remark may be applied to the examination of the thorax and ab- 
domen. 

At my last lecture I endeavoured to impress upon you the fact 
that there can be no doubt that persons have been occasionally 
starved to death in fever ; and laid before you some remarkable 
facts connected with the influence of protracted abstinence on the 
general system, as well as on the brain and digestive tube. I 
endeavoured to show that long-continued denial or want of food 
generates symptoms bearing a very close resemblance to those which 
are observed in the worst forms of typhus. Pain of the stomach, 
epigastric tenderness, thirst, vomiting, determination of blood to the 
brain, suffusion of the eyes, headache, sleeplessness, and, finally, 
furious delirium, are the symptoms of protracted abstinence ; and 
to these we may add, tendency to putrefaction of the animal tissues, 
chiefly shown by the spontaneous occurrence of gangrene of the 
lungs. It has been shown by M. Guislain, physician to the hospital 
for the insane, at Gand, that in many instances gangrene of the 
lungs has occurred in insane patients who have obstinately refused 
to take food. Out of thirteen patients who died of inanition, nine 
had gangrene of the lungs. You perceive, then, that starvation may 
give rise to symptoms of gastric disease, to symptoms of cerebral 
derangement, and to mortification of the pulmonary tissue. It is not, 
therefore, wrong to suppose that when a system of rigorous absti- 
nence has been observed in fever, and when food has been too long 
"withheld, because, forsooth, the patient does not call for it, and 
because his natural sensibilities are blunted and impaired — it is 
not, I say, unreasonable to suppose that gastric, cerebral, and even 
pulmonary symptoms may supervene, analogous to those which 
result from actual starvation. 

An attentive consideration of the foregoing arguments has led 
mC; in the treatment of long fevers, to adopt the advice of a country 
physician of great shrewdness, who advised me never to let my 
patients die of starvation. If I have more success than others in 
the treatment of fever, I think it is owing in a great degree to the 
adoption of this advice. I must however, observe, that great dis- 
crimination is required in the choice of food. Although you will 
not let your patients starve, do not fall into the opposite extreme: 
you must take care not to overload the stomach. When this is 
done, gastro-enteric irritation, tympanitis, inflammation, and exas- 



TREATMENT OF FEVER. 281 

perated febrile action, are the consequences. I have witnessed 
many instances of the danger of repletion in febrile diseases. A 
case of this kind occurred some time back in this hospital, in a boy 
who was recovering from peritonitis. In another case, in private 
practice, an incautious indulgence in the use of animal food was 
followed by a fatal result. A young lady ate some beefsteak, con- 
trary to my orders, at an early period of convalescence from fever, 
relapsed almost immediately, and died in thirty-six hours. Food 
must be given with great care and judgment, particularly in the 
beginning of fever. For the first three or four days, particularly 
if the patient is young and robust, water, weak barley water, and 
whey, will be sufficient. After this I am in the habit of beginning 
with some mild nutriment. What I generally give is some well 
boiled gruel, made of groats, and flavoured, if there be no tendency 
to diarrhoea, with sugar and a small quantity of lemon juice. The 
ordinary oatmeal gruel does not answer sufficiently well for this 
purpose, for it is apt to produce griping and diarrhoea, symptoms 
which are extremely disagreeable in the commencement of fever, 
and which often lead to others of a more troublesome and formi- 
dable character. I am also much in the habit of giving a little 
thin panado, morning and evening, during the latter part of the 
first, and the beginning of the middle stage of fever. A small 
slice of bread is slightly toasted, and boiling water is poured on a 
tablespoonful of the crumbs, in sufficient quantity to make a thia 
panado, of which the patient takes a tablespoonful two or three 
limes a day. It may be flavoured with a very small quantity of 
lemon juice and sugar, if there is no tendency to diarrhoea ; but 
where this exists, or where you are administering mercurials, I 
think you should be cautious in the use of acids. Although me- 
dical men are of late rather less cautious in giving acids during 
the use of mercurials, I think the practice is not entirely devoid of 
danger, and I think our predecessors were right in withholding 
them under such circumstances. You will begin, then, on the 
third, fourthj or fifth day, according to circumstances, with a little 
gruel ; and after two or three days you may add a little panado, 
giving, as I have already observed, a spoonful of either every third 
hour. As the fever advances you may add some mild animal jelly 
or broth ; and one of the best kinds of nutriment in the middle and 
latter stages of fever, is chicken broth. I do not speak here of 
chicken water; I mean good and well made chicken broth. Give 
this, but give it in small quantities, and with great caution at first. 
Watch the eflfects of the few first spoonfuls ; it may act injuriously, 
and you should give it up, at least for some time, if it produces any 
bad efi^ects. U it brings on heaviness, sickness of stomach, flushing 
of the face, excitement of pulse, and increased feverishness, give it 
up, and return for some time to the gruel and panado. You can 
try it again in a day or two; for although your patient does not 
bear it to-day, he may to-morrow or the day after ; and it is a most 
fortunate circumstance when it agrees with him, for, as I have 

24* 



282 GRAVES'S CLINICAL LECTURES. 

already observed, it is the best kind of nutriment you can give in 
the middle and latter stages of fever. The best mode of giving it 
is to make the patient take a tablespoonful of it regularly every 
third hour, or oftener if necessary. 

Recollecting the tendency to diarrhoea and intestinal irritation in 
fever, you will be extremely cautious in allowing your patient the 
use of fruits. Indulging patients in the use of grapes and oranges 
is a very popular, but, in my mind, very hazardous and improper 
custom. I have on many occasions seen persons injured by fruits 
of this description. Stewed and roasted apples are still more dan- 
gerous ; they are apt to produce tormina, flatulence, diarrhoea, and 
intestinal inflammation. All acid or raw fruits have a tendency to 
produce irritation of the stomach and bowels, and should be avoided 
altogether or very sparingly used. 

One general observation as to the administration of food and 
nutriment in fever. All kinds of food and nutriinent should be 
given by day, and the patient should, if possible, be restricted to 
ihe use of fluids by night. The natural habit is to take food by day 
and not by night, and in sickness, as well as in health, we should 
observe the natural habits of the economy. With respect to drinks, 
the mildest, of course, should be preferred : on this point most per- 
sons are generally agreed, and it will be unnecessary for me to 
detain you with any particular observations. There is one error, 
liow^ever, which is very frequently committed in the use of drinks 
in fever ; patients are generally allowed to drink too much. It 
may be urged that they have a strong desire for fluids ; but they 
should not be gratified in everything they wish for. They labour 
under a constant state of nervous irritation and restlessness, and 
will beg of you to do twenty different things to relieve their imme- 
diate feelings ; but it would be just as improper to give them large 
quantities of drink every time they desire or call for it, as to in- 
dulge them in any momentary whim which may be the ofl^spring 
of their disordered and changeable fancy. The continued swilling 
of even the most innocent fluids will bring on heaviness of stomach, 
nausea, pain, and flatulence, and predisposes to congestion and 
intestinal irritation. From the mere ingesting of a large quantity 
of the simplest fluid, you will frequently see well-marked symptoms 
of gastric irritation arise during the course of fever. This is not a 
picture drawn from imagination; I have witnessed it on many 
occasions during the course of my practice. It is extremely pain- 
ful, indeed, to be obliged to refuse drink to a patient labouring under 
intense thirst; but you should never allow them to take a large 
quantity of fluid at a time : you should impress upon them the 
danger attendant on such a practice, and tell them that a spoonful 
or two, swallovvod slowly, allays thirst more effectually than drink- 
ing a pint at a time. The sensation of thirst, as you all know, is 
almost entirely confined to the fauces and upper part of the pharynx, 
and it is as much relieved by a small quantity swallowed slowly 
and gradually, as by a large quantity gulped down at once. 



TREATMENT OF FEVER. 283 

Besides the simple fluids, there are other drinks required in fever. 
Beer, ale, porter, wine,, tea, and coffee, are also frequently used in 
the treatment of" fever, and are of the utmost value when employed 
on appropriate occasions ; they are adjuvants of the highest im- 
portance in the dietetic management of fever, and it will require 
some time to explain the rules by which you should be guided in 
their administration. I shall, therefore, speak of them according to 
the indications with which they are given*; and, first, of tea and 
coffee. li!ou are aware that we are constantly in the habit of 
ordering micdicines to diminish nervous irritation or restlessness, 
and to procure sleep; but I believe we are not much in the habit 
of prescribing remedies Vv'hich produce an opposite state of the sys- 
tem. We give sedatives and narcotics to tranquillise, to produce a 
species of exhaustion of the mental faculties, and to bring on sleep; 
and I do not see any reason why we should not also administer 
expergefacients, or remedies calculated to maintain intellectual ac- 
tivity, and keep the patient awake. Among those remedies which 
are most frequently employed for the latter purpose, are tea and 
coffee. You have lately seen the use we made of an infusion of 
green tea, in a case of narcotism which occurred in the fever ward. 
A man who was in the latter stage of fever, and labouring under 
great nervous excitement and total loss of sleep, was ordered an 
opiate enema, after we had tried various other means without suc- 
cess. During the course of the evening he got twelve drops of 
black drop, with two ounces of mucilage of starch, in the form of 
enema, and soon after fell into a sound sleep. When we came 
next morning and inquired after him, everything was reported to 
have gone on well ; the opiate enema had answered the purpose 
completely, and the man was still sleeping soundly. We found, 
however, on a more accurate examination, that he was in a kind 
of lethargic state, and could scarcely be roused. When addressed 
in a loud tone of voice, he raised himself heavily and slowly, half 
opened his eyes, gave a brief answer to our questions, and then, 
leaning back on his pillow, dropped asleep. Observe here the 
danger connected with this state. He was in an advanced stage of 
fever, had been restless and sleepless, and had suddenly passed to 
an opposite state. The rapidity with which coma had supervened 
on sleeplessness, and the danger of fatal congestion of the brain 
cornino-on, gave me considerable alarm. There was no use, how- 
ever, in thinking of what had been done; the man's state called for 
prompt and decided measures, and we proceeded at once to attack 
the symptoms of our own creation. One of the gentlemen went 
down and got some green tea, of which he made a strong infusion, 
and administered a strong dose of it to the patient. This had the 
desired effect; the symptoms of coma gradually disappeared, and 
when I came to see him in the afternoon, he was quite out of dan- 
ger. Green tea was first introduced here as an expergefacient in 
the treatment of coma by Dr. Edward Percival, son to Dr. Percival 
of Manchester ; and some years back he read a paper at a meeting 



284 GRAVES'S CLINICAL LECTURES. 

of the College of Physicians, in which he brought forward several 
cases of coma and stupor, in which green. tea had produced the 
most favourable effects. On the continent they generally use strong 
coffee for the same purpose. Whether these beverages produce 
this effect by their influence on the circulation, or on the nervous 
system, I am not prepared to say; but there cannot be a doubt of 
their efficacy and value in many cases of this description ; and I 
am frequently in the habit of using both with this intention. 

While on the subject of expergefacients, I shall beg leave to read 
for you a very curious case from the 13ih number of the Boston 
Medical and Surgical Journal, in which an expergefacient of a less 
agreeable character was eniployed to rouse a patient from the 
lethargic stupor brought on by a large dose of laudanum. There 
are some transatlantic peculiarities of expression in the detail of 
this case, but I have no doubt of its being correct. It is entitled 
" a case of successful treatment by flagellation, where a large dose 
of laudanum had been taken." And the author, Dr. Joseph Barrett, 
of Middletow^n, Connecticut, proceeds as follows : — 

" Tincture of opium is not unfrequently resorted to for destruc- 
tive purposes. It is also, unfortunately, and too frequently, taken 
by mistake, and proves fatal beiore efficient means can be adopted 
to counteract its deleterious effects on the system. I am induced, 
therefore, to offer a short statement of a case of poisoning with 
laudanum that fell under my care several years since, for the fol- 
lowing reasons: first, the success that attended the mode pursued, 
and, secondly, from not having met with any such means recorded, 
to my knowledge,* either in works on medicine, or in treatises on 
poisons. 

Observe, it is not I that am speaking here, but Dr. Barrett, of 
Middletown, Connecticut. 

" In the year 1822, February 23d, I was called on to see Mr. 
Wright Harris, (this was in the state of New York,) who had 
intentionally taken a large dose of laudanum for the purpose of 
destroying himself. He had committed this act during his absence 
from home, under circumstances which it is not important to relate. 
Much time, about three hours, was, therefore, lost, before any effec- 
tual measures could be adopted for his relief. His case, as I found 
him, appeared to be altogether hopeless. Before my arrival, eme- 
tics and various drinks had been tried, besides frictions, and con- 
stant, though ineffectual attempts, had been made to irritate the 
oesophagus by feathers. All these means had failed, and the 
patient was in such a profound sopor, that apparently nothing but 
warmth remained to indicate that life had not already become ex- 
tinct. The quantity of laudanum taken was ascertained to be one 
ounce and a half. The case appearing so desperate, justified rae 
in the course of treatment which I was, under existing circum- 
stances, then obliged to adopt. 

* This practice, though not generally adopted, has been recommended by 
several authors in Europe, 



FLAGELLATION IN A CASE OF POISONING. 285 

" Internal renaedies having entirely failed, there was no chance 
left but for high external excitements. I therefore determined to 
use vigorous measures. I commenced with flagellations, using 
long, pliant, fresh twigs to the palms of the hands and soles of the 
feet. These were briskly applied, and in a short time gave indica- 
tions of uneasiness and pain. This treatment was unremittingly 
pursued till the man spoke, and complained of being pained by the 
whipping, when this severe appliance was relaxed ; but on so 
doing, he instantly sunk into a profound stupor, from which he 
was again only roused by the severity of the whipping. It required 
the aid of a number of men to take turns in the flagellation, as well 
as to support and walk him about ; for a cessation of the use of the 
rods was followed by instantaneous stupor. After about six or 
eight hours under this course, the stupor was lessened, and the 
severity of the flagellation mitigated: but as the case required con- 
stant high excitement, it was still repeated at intervals, till event- 
ually the exercise of walking was sufficient to keep him awake. 
This was in about twelve hours from the commencing with the 
flagellation. He afterwards experienced but little inconvenience 
from his hands and feet, and was perfectly restored in a few days 
to his usual health. I would here state that the first proposal 
made by me to adopt flagellation, as the only hope, was objected to 
by the persons present, from its carrying with it the semblance of 
unkindness towards what was regarded by them as a corpse ; and 
it was not till the application of the rods by myself, in the first 
instance, that I obtained the aid of those present; but as soon as 
the patient began to move, and at last spoke, they took hold with 
alacrity, and by dividing themselves into relief parties, they very 
cheerfully, and rather amusingly, kept up the castigation so long 
as the state of the patient required it at their hands. He by no 
means seemed to relish this harsh proceeding, and in return gave 
his attendants several severe blows. If while lifting his arm to 
give a blow, the flagellation was then entirely suspended, the arm 
would instantly sink powerless; to such a degree had the effects of 
the narcotic drug prevailed over the nervous system, that nothing 
but the torture of the rods could rouse him. On his recovery, it 
was said that the man's wife was highly satisfied with this reme- 
dial course, which was believed to have a good efl^ect upon his 
subsequent conduct." 



286 GRAVES'S CLINICAL LECTUEES. 



LECTURE V. 

Treatment of typhus fever — Tympanites often the consequence of inattention to diet, 
or to overdosing vi^ith purgatives — Thirst in fever frequently dependent on the state 
of some internal organ — Blisters, employed as stimulants or evacuants, excite the 
vital action of the capillaries — an important remedy where cerebral affection is ap- 
prehended — Signs of approaching cerebral symptoms — Tartar emetic solution, and 
ointment — The latter used with success in some desperate cases. 

Before T proceed to speak of the diet and remedies to be employed 
in the treatment of typhus, allow me to make a few observations. 
There is a patient at present in the fever ward, whose case shows 
the necessity of strict attention and incessant watchfulness on the 
part of those who have the management of bad cases of fever. A 
man who has been labouring under deliriufn, with symptoms of 
cerebral excitement and congestion, was ordered the tartar emetic 
solution, with the view of reducing the increased vascular action ; 
but on inquiry this morning, we find that be has taken no medi- 
cine, and that his symptoms have been allowed to go on unchecked 
for twenty-four hours. He refused to take his medicine, and the 
nurse very improperly neglected to report the circumstances of the 
case, in order that proper steps might be taken to remedy so dan- 
gerous an omission. Thus a whole day has been lost at a most 
critical and important period of fever. There can be no excuse 
for such negligence as this, for it could be easily remedied. Pa- 
tients in this state have always more or less thirst, and a spoonful 
of the tartar emetic solution could be mixed with whey or cold 
water, and administered in this way without his knowledge, or if 
he refused to drink any fluid, it might be given in the form of 
enema. There is no excuse, therefore, for such negligence ; and 
when you recollect the state that such patients are in — their nervous 
excitement, incessant raving, agitation, struggling, and sleepless- 
ness — you will be able to appreciate the dangerous, and even fatal, 
consequences that may arise from culpable neglect of this kind. 

At our last meeting I spoke of the use of food and drink, and 
laid before you my views of the most appropriate articles of diet 
in the various stages of the fever. I told you that I attributed much 
importance to the use of a proper regimen, and that I looked upon 
the observance of this principle as a main cause of success in the 
treatment of typhus. I think it is chiefly owing to our care in this 
respect, that so few of our patient have tympanites. Now and 
then we have cases of fever with tympanites and diarrhoea, but in 
the majority of instances, these are persons who have been under 
treatment before admission, and who have been too much purged. 
The use of drastic purgatives in the early and middle stages of 
typhus, is one of the most fertile sources of subsequent evil, and 
there are few evils of greater magnitude than tympanites with 
diarrhoea, and gastro-enleric inflammation, particularly im the latter 



TREATMENT OF FEVER. 287 

stage of fever. Now, if you inquire into the history of the cases 
in which these symptoms are most distinctly marked, you will find, 
that in at least two-thirds, powerful cathartics have been employed, 
not once, but repeatedly, in the commencement of the disease. 
Almost all cases, in which calomel and colocynth, or aloes, fol- 
lowed by black draught, have been liberally used in the commence- 
ment, become tympanitic, frequently at a very early period. The 
same mischief, but in a less degree, is apt to occur where a system 
of strict abstinence has been enforced, and continued undeviat- 
ingly for a considerable length of time. Want of food, even in the 
healthy state of the system, is apt to produce flatulence, weakness, 
and distension of stomach, and in many instances gives rise to 
very serious forms of gastro-intestinal irritation. The dihe ahsolue 
is very apt to produce the same effect in fever. Even the abuse of 
drinks of the simplest and m.ost innocent description, is apt to pro- 
duce flatulence, distension, and a tendency to tympanites. Hence 
the value of the rule which I laid down in a former lecture, viz., to 
allow the patient only small portions at a time, and to order him 
to swallow them slowly. The abuse of the ordinary drinks, as 
common water, whey, barley-water, soda and seltzer waters, and 
effervescing draughts, is a frequent source of tympanitic swelling 
in fever. In this hospital we seldom prescribe effervescing draughts, 
and never give them in the ad libitum quantity which some per- 
sons recommend. Thirst can be sufficiently assuaged by the use 
of whey, or common water, acidulated with currant jelly or rasp- 
berry vinegar, given in small portions, and at certain intervals. 
Sometimes you will succeed efTectually in controlling feverish 
thirst by the use of a very light infusion of cascarilla, acidulated 
with a small quantity of muriatic acid. I have seen this employed 
with success by Mr. Kirby, and I have often prescribed it myself 
with the best effects. Very often you will find that a small quan- 
tity of some light bitter, slightly acidulated, will appease the mor- 
bid thirst of fever more effectually, and for a much longer period, 
than large draughts of water, or any of the fluids usually employ- 
ed for the same purpose. You should always bear in mind, that 
thirst in fever does not exclusively depend on a dry or parched 
state of the mouth or fauces, but lies much deeper in the system, 
and has its origin in some peculiar derangement of the nerves, most 
probably of those belonging to the ganglionic system. In going 
through a fever ward, you will meet with numerous illustrations 
of the truth of this position ; for you will find one man with a 
moist tongue and fauces, and yet labouring under insatiable thirst, 
while you will observe another with parched tongue and throat, 
and yet without any desire whatever for fluids, or any choice as to 
their temperature. We had two examples of this in the fever ward 
during the past week. One patient with a moist tongue was inces- 
santly calling for drink, while another man, who had his tongue 
almost perfectly dry, exhibited a very remarkable indifference to 
fluids. 



288 GRAVES'S CLINICAL LECTURES. 

There is one curious circumstance connected with the sensation 
of thirst in inflamnnatory diseases, which deserves attention. I 
lately attended a fatal case of metritis after delivery, in consultation 
with Mr. Hayden and Dr. Ireland. These gentlemen pointed out 
to me the singular fact, that the patient's thirst was instantly in- 
creased to an intolerable degree, by pressure applied to the womb. 
I merely notice the fact here as being extremely curious, leaving 
the explanation of it to those who are more conversant with such 
investigations. i 

Having said so much of food and drink in fever, I come now to 
speak of external and internal remedies, and first of blisters. 
Blisters are employed in a variety of diseases, but are followed by 
very different physiological effects, and capable of serving very 
different purposes, according to their mode of application. In 
fever they aie generally employed either as stimulants, or as eva- 
cuants and derivatives. As stimulants, they may be used with the 
intention of rousing the depressed energies of the system in general, 
by their action on the nervous and circulating S3'stems, or of sti- 
mulating the torpid functions of some particular part or organ. 
With tliis object in view, they are applied as laying blisters — that is 
to say, for a space of time not exceeding two or three hours, and 
solely with the intention of producing a stimulant effect. You 
have seen some cases of fever in our wards, in which the powers 
of life were greaily depressed, the extremities cool, the action of 
the heart feeble, the pulse weak, respiration short and imperfectly 
performed, and a tendency to fainfess and sinking; and you have 
observed l!iat in such cases we derived great benefit from the ap- 
plication of flying blisters over the region of the heart, the epigas- 
trium, chest, and inside of the legs and thighs. We applied our 
blisters in these situations, left them on for two or three hours, and 
then removed them; and you have seen them, when employed in 
this way, succeed in rousing the vital energies, the depressed action 
of the heart and capillary system, and the flagging state of the 
respiratory function, as shown by the increased strength of the 
pulse, the more general diffusion of heat, and the renewed play of 
the various functions. 

In such cases where the stimulant effect alone is required, it 
■would be wrong to leave the blisters on longer than two or three 
hours; it will be quite sufncient if they prove merely rubefacient, 
or, at most, vesicate so slightly as to give to the blistered surface 
the appearance of a miliary eruption. Here you have all the sti- 
mulant effects of blistering, but not followed by their debilitating 
consequences. You are aware that blisters applied in the ordinary 
way have a twofold effect; they first rouse, and then depress; 
acting primarily as stimulants, and secondarily as evacuants. 
They first act as stimulants, producing pain, heat, and redness of 
the part; after a few hours these symptoms diminish, and are fol- 
lowed by an effusion of serum — in fact, a quantity of white blood 
is abstracted fronri the cutaneous capillaries, and in this way an 



TREATMENT OF FEVER. 289 

evacuation is produced, calculated to diminish any accidental con- 
gestion in neighbouring parts. The capillaries, by means of their 
increased action, draw a quantity of white blood to the part; and 
in saying this, I think I am only using a perfectly physiological 
expression ; for the quantity of circulating fluid in any part of the 
body must depend on the vital action of the capillary vessels of 
that part. It is to the peculiar state of the capillary vessels that 
the quantity of blood in any part is to be referred, and not to the 
force or frequency of the heart's action. It is by means of changes 
produced in them that the phenomena of active congestion and 
inflammation are produced: the capillaries of the aflfected part 
enlarge, increase in number, and multiply, and those which were 
invisible become visible. These phenomena have been falsely at- 
tributed by Hastings and others to debility and impaired action of 
the capillaries. 

Enlargement or distension of the capillary vessels, whether the 
result of active local congestion or inflammation, is quite a different 
process, and bears a very close analogy to the enlargement of the 
anastomosing arteries of a limb in which the principal vessel has 
been tied. The afflux of blood, and the vascular distension, are 
not the consequences of debihty or of relaxation, but of an actual 
increase of vital action. In the enlargement of the anastomosing 
arteries which takes place iti cases of collateral circulation, the 
increase of size is not confined to the arteries connected with the 
main trunk ; it commences simultaneously in the more distant set 
of branches, beginning in the smaller ones, and then gradually 
extending to the larger. This is a proof that the enlargement of 
the vessels depends solely on a vital action inherent in themselves, 
and is not the result of a mere passive distension, or of an in- 
creased determination of blood to the part, produced by the action 
of the heart. 

Dr. Houston, in a very important paper on the circulation in a 
monstrous foetus, without head or brain, published in the last 
number of the Dublin Medical Journal, has proved almost to a 
demonstration, that, in the case referred to, the circulation in the 
placenta could not be carried on, unless by the vital attractive 
power of the capillaries. It is owing to this power that vascular 
tumours bleed so profusely when wounded or scratched : and yet, 
if you cut through the artery which supplies them, there will not 
be any considerable hemorrhage. When you divide the artery, 
the capillaries cease to draw blood to the part, and the hemorrhage 
is slight; but if you wound the tumour itself, the blood is attracted 
to the part as fast as it drains oflf, and a profuse hemorrhage is the 
result. 

You should also bear in mind, that there are many animals 
which are without a heart, and yet in which the functions of the 
circulation are adequately performed. We have numerous in- 
stances of human monsters born without any trace of a heart, and 
yet well nourished and developed. In cases of this description 

25 



290 GRAVEST CIIMCAL LECTOB^L 

how is the circQiation carried on, or by what power is iJbe blood 
impelled through the vessels ? I do not see what cause we can 
refer it to, except the vital agency and attractiTe power of the ca- 
pillar}^ system. I nsention these facts becaose, in the treatment of 
inflammatory aod fdirile auctions, it is important that joa should 
have correct physiological views, and that yoo should bear in mind, 
that each part and oi^n of the body may have its vital action de- 
ranged, or, in other words, may become congested and inlBamed, 
independently of the action of the heart or the general circulation. 

Bhsters, then, produce fii^ increased ac^tion of a part, and then 
act as evacoants. They also stimulate the system generally ; bat 
if left on UQtil foil vacation is produced, they act as evacoants 
and depletives, and lower the general tone of the economy. I have 
frequently observed this succes^on <if events in chronic cases, in 
which it was found necessary to blister rqseatediy during the course 
of the disease. The patients g^eoerally told me that they fi^t better 
and lighter on the day on which the Mister wasapfdied, baton the 
next day they usually felt weaker and more depre^ed; and this 
slate sometimes lasted more than a single day. You may therefore 
apply blisters as excitants and stimulants, or you may employ them 
as evacuants and depletive; yet there are many persons who seem 
to forget this distinction. If .in a case of inflammation, occurring 
in a low state of the system, you propose to apply a certain number 
of leeches over the inflamed oi^n, thej say no ; bet they have no 
hesitation in applying a large blister, l«iving it on until it fnudi 
foil vesication, and thus abstract a consideraUe porticHi of 
blood from the system. 

You will not expect me to lay down any general rules for the 
use and application of blistering in fevers; you wifl find all these 
matters su&ieotly explaizied io y<iur books and manuals. I am 
not giving any thing like a regular outline of the treatment of] 
fever ; in fact I pass, per saltum, from one pcHut to another, without i 
any attention to order or method. Tou <:an read methodical trea-' 
tises, and then compare them with such detached observaticms as Ij 
shall make. And here allow me to make some detached observar-'^ 
tions on that peculiar state oi the brain which we most commonly; 
observe in the middle stage oi typhus, and in which blisters fonn;; 
one of our most eScieot, and in some instances our only mode of] 
relief. In many of the cases of typhiK which come under ota 
observation in hospital, we frequaitly me^ with a tr^n (^ symp?' 
toms strongly calculated to per{Jex and pozde^ and which slionld^ 
seldom exist in fever regulariy treated; these are chi^y 
which are admitted in the middle or latter stage of the disease, and 
at a period when the patient's state of intellect is such as to preclude 
the hope of obtaining any satisfactory information from a peraonal 
examination. 

A man in the lowest class of life,'and at a distance from medical 
aid, is attacked with fever; for the first ^ght or ten days he is 
either impn^rly treated or altogether neglected, and in tUs state 



TREATMENT OF FEVER. 291 

symptoms arise and superinduce others, giving rise to the most 
unfavourable complications, and rendering the cure difficult, if not 
impossible. Now of all the symptoms which occur in cases of 
feveVf where the state of the principal organs have been neglected, 
there are none more formidable, or more fatal, than the cerebral ; 
nor is there any local affection in fever, in which the value of pre- 
vention is so unequivocal and decided. What I wish to impress 
upon you is, that you should always anticipate the cerebral symp- 
toms in fever. Never allow the cerebral symptoms to explode — 
watch the first scintill83 of cerebral excitement — repress the com- 
mencing mischief, and do not allow your patient to be overtaken 
by formidable inflammation of the brain. This is one of the points 
in which I have changed my practice. I never allow cerebral 
symptoms to become established in any of the cases which I have 
treated of late. Every writer will tell you that when the patient's 
face is flushed, his eyes suffused, and when he complains of head- 
ache and intolerance of light, you should leech and blister his 
head, give him purgatives, tartar emetic, James's powder, and the 
medicines calculated to bring down cerebral excitement: but a 
careful and observant practitioner will anticipate all these symp- 
toms, although there is as yet no particular flushing of the face, 
headache, or suffusion of the eyes; and though the patient is still 
quite rational, he will recognise threatening disease of the brain 
long before it commences, and take proper steps to prevent its ex- 
plosion. Watch the functions of the brain attentively, and they 
will inform you, in almost every case, of the approach of cerebral 
symptoms. You will find in patients who are about to have cere- 
bral symptoms, a degree of restless anxiety, and a higher degree 
of energy than accords with their condition ; and they either do 
not sleep at all, or their sleep is broken by startings and incoherent 
expressions. When you speak to a person in this state, he answers 
in a perfectly rational manner ; he will tell you that he has little 
or no headache; and were you to be led away by a hasty review 
of his symptoms, you would be very likely to overlook the state of 
the brain. If you inquire closely, you will find that he scarcely 
ever sleeps, or even dozes — that he is irritable, excitable, frequently 
incoherent, and muttering to himself. Under such circumstances, 
although there is no remarkable heat of scalp, suffusion of the eye, 
or headache, I am frequently led to suspect the supervention of 
cerebral symptoms, particularly about the ninth or tenth day of 
the fever (for it is generally about this period that cerebral symp- 
toms begin to manifest themselves) ; and whenever I observe these 
premonitory indications, I never hesitate in taking proper measures 
to anticipate the evil. I immediately order the hair to be shaved 
off, and blister the whole scalp. Thus, at the period when disease 
of the brain would most probably have set in, I have the whole 
external surface of the head pouring out serum, or even suppurat- 
ing: and when by this treatment I have opposed a barrier to the 
further progress of the disease, the exhibition of a little tartar 



292 GRAVES'S CLINICAL LECTURES. 

emetic will soon remove every trace of it. In laying down this 
plan of treatment, I have supposed that the patient has been pro- 
perly treated from the beginning, and that the earlier symptoms of 
inflammatory excitement have been combated by bleeding, leeching, 
and other appropriate depletory measures. 

There is, on the other hand, an opposite state of the patient, 
wiiich in like manner informs me that danger to the brain is at 
hand. In this case the patient is almost continually sleeping. 
When you enter his chamber in the morning, and ask how he does, 
his attendant generally tells you that he has passed the night most 
favourably, and that he has slept without almost ever waking since 
your visit on the preceding afternoon. If he awakens to take 
drink, he quickly drops asleep again, and when you arouse him he 
looks rather heavy ; there is some slight efiusion of the tunica 
adnata, and some appreciable congestion about the external parts 
of the face and head. Persons in this state, though apparently 
doing well, and even where they have been properly treated in the 
beginning, about the ninth or tenth day begin to rave, and exhibit 
undoubted proofs of congestion and excitement of the brain. Now, 
in all cases of this description be on your guard, and do not allow 
symptoms of dangerous import to steal on you. Here you will 
derive great benefit from the use of blisters. I was lately called to 
a very rem.arkable case of this kind, at some distance from Dublin. 
The patient slept almost constantly, and complained of no head- 
ache or heat of scalp. From an attentive examination of the case, 
however, I was led to predict the approach of cerebral symptoms. 
Observe, this was a case of spotted fever ; and in this form of 
fever you can predict the occurrence of such symptoms with a 
greater degree of confidence. The patient's pulse was 96, his 
tongue presented nothing worthy of remark, his behaviour and 
speech rational, and his sleep almost constant. Recollecting, how- 
ever, the period of the fever, and observing carefully the condition 
of the cerebral functions, 1 had his head shaved and blistered. 
Notwithstanding this precaution, his cerebral symptoms had pro- 
ceeded so far that he subsequently got a slight attack of paralysis 
of the face and tongue, accompanied by a fixed state of the pupils, 
which would neither contract nor dilate. After having blistered 
his head extensively, I gave him the tartar emetic solution, to the 
amount of one-eighth of a grain every second hour. These mea- 
sures were completely successful in removing the cerebral symp- 
toms, and I have no doubt that the active precautions which had 
been taken were the means of saving his life. 

Now there is one symptom connected with cerebral excitement 
in fever which is well worthy of your notice, as its existence is 
often sufllicient of itself to give timely intimation of the approach 
of irritation or inflammation of the brain. This is, the state of the 
respiratory function. In fever, the breathing will often announce 
the approach of cerebral symptoms for days before their actual 
occurrence. When, in cases of typhus, you find the patient's 



TREATMENT OF FEVER. 293 

breathing permanently irregular, and interrupted by frequent sigh- 
ing — when it goes on for one or two minutes at one rate, and then 
for a quarter or half a minute at another rate, you may rely upon 
it that sooner or later an affection of the brain will make its ap- 
pearance. You will frequently observe the same kind of breathing 
preceding attacks of apoplexy and paralysis, and indeed it was the 
occurrence of this symptom, in these and other cases in which the 
functions of the brain were deranged, that first drew my attention 
to this kind of breathing. The first time it engaged my attention 
was in a remarkable case of an apoplectic nature which I sat up a 
whole night to watch. On recollection, I found that I had fre- 
quently observed an analogous state of the respiratory function in 
fever on several occasions, although its connection with excite- 
ment of the brain had not struck me before. I speak here of irre- 
gularity of breathing independent of any pectoral affection. But 
when the patient breathes in a permanently irregular manner, at one 
time at a certain rate, and at another at a different rate, — when his 
respiration is suspicious and heaving, without any disease of the 
chest or great debility, — you will have some ground to suspect the 
existence of cerebral derangement. I am in the habit of calling 
this kind of breathing cerebral respiration, because my experience 
has told me that it is almost invariably connected with oppression 
and congestion of the brain. To recapitulate : — When you find a 
patient in fever lying constantly awake, or when on the contary' 
you find him continually slumbering, — when there is a certain 
quickness of manner and irritability, — and when the cerebral re- 
spiration has been noticed for some time, without any concurrent 
debility or pulmonary disease, — under such circumstances, you 
may, in cases of maculated typhus, predict the approach of cere- 
bral symptoms ; and the period about which they generally mani- 
fest themselves, is the eight, ninth, or tenth day. JNow in cases 
of this description, — if you have previously used leeches and anti- 
phlogistics to a sufficient extent, — your best plan will be to shave 
and blister the whole scalp. Dr. Little, of Belfast, and Mr. Kirby, 
of this city, have fallen into the same train of ideas, and employ 
blisters at a very early period of the disease, with the view of com- 
bating cerebral excitement. In a recent instance, in private prac- 
tice, I think I saved the life of a young gentleman In Harcourt 
street by extensive blistering of the scalp on the fourth day of fever. 
We were not accustomed to blister at this early period of fever. 
Formerly it was the practice to bleed and apply leeches for several 
days together, and never to have recourse to blistering until to- 
wards the latter stage of the disease. In common inflammation or 
in arachnitis, we do not blister until we have carried depletion by 
the lancet, leeches, and purgatives, as far as the patient's strength 
will allow. But this is not the case in fever : the cerebral conges- 
tion and irritation, or inflammation, ( call it which you will,) which 
accompanies typhus, differs essentially from ordinary arachnitis or 

25* 



294 GRAVES'S CLINICAL LECTURES. 

encephalitis, and requires very often a treatn:ient strikingly dif- 
ferent. 

One pliysiological fact connected with sleep may be noticed here. 
It has been stated by Mr. Mayo, that the pupils are contracted 
during sleep. This is in itself a very curious fact, and I was 
anxious to verify it. Now we had an excellent opportunity yester- 
day morning of trying what the state of the pupil was in two pa- 
tients who lay soundly sleeping in the fever ward. We came up 
softly to them as they lay on their backs, and in a most favourable* 
situation for observation, just under one of the windows ; and 
having opened the eyelids, found that the pupil was actually con- 
tracted to the size of a pin-hole. It remained in this state for a 
while, and then expanded, when they awakened. This is a very 
curious fact, and appears to be a very beautiful instance of the pro- 
tective care of nature. To protect the eye while we sleep, nature, 
as it were, draws the curtain, and thus defends the delicate organ 
from any accidental dazzling, at a period when consciousness slum- 
bers, and is off its guard. 

Blisters applied extensively to the shaven scalp, are not only 
valuable in fever, but also in other diseases, and that under cir- 
cumstances in which little benefit could be expected. The same 
effects may be produced by rubbing the whole scalp with tartar 
emetic ointment ; but from the pain and inflammation it produces, 
this proceeding is seldom adopted. I have, however, occasionally 
employed it; and on tw^o recent occasions with the most fortunate 
results. A friend of mine had lost two children from hydrocepha- 
lus. About five weeks ago another child, an extremely fine boy, 
was attacked with symptoms of the same disease. After having 
laboured for a fortnight under fever, with great restlessness, vomit- 
ing, and diarrhoea, he was observed to utter frequently that faint 
cry which is so characteristic of hydrocephalus, and to roll his 
head 'constantly from side to side. These symptoms were sooa 
afterwards succeeded by constant motions of the right arm and leg;, 
and subsequently by paralysis of the opposite side. I was con- 
sulted before the paralysis occurred, and advised the child's father 
to have the whole of the blistered scalp well rubbed with tartar 
emetic ointment. The boy recovered completely. I derived also 
a very striking advantage from the use of the same remedy in a 
very remarkable epidemic which attacked a family in the neigh- 
bourhood of Rathmines, and which w^as w^itnessed throughout its 
whole course by my friend Dr. Burke and myself. One of the 
family, a young lady, was attacked with symptoms of fever, ac- 
companied by pain in the back of the head and stiflfness of the 
neck. After a few days, symptoms of inflammation of the cere- 
bellum and upper part of the spinal cord became developed. About 
the seventh day she got strabismus, and soon afterwards was at- 
tacked with convulsions; the pupil became permanently dilated^ 
and she was quite blind. I was called to see her at this period, 
and found her almost in a state of insensibility, with involuntary 



TREATMENT OF FEVER. 295 

discharge of urine and fgeces, cold extremities, and irregular pulse. 
Thinking that nothing could be done for her, I was about to leave 
the room, when I asked the nurse, could she swallow ? She re- 
plied she could, and immediately proceeded to offer the young lady 
some drink, which she swallowed without any difficulty. This at 
once arrested my attention. I said to myself, if this patient can 
swallow, she must be still conscious, and while she is so, there is 
a chance of saving her. I ordered the whole of the scalp, which 
had been previously blistered, to be rubbed with tartar emetic oint- 
ment ; violent inflammation ensued, and she recovered completely. 
But the curious part of the case is this : — her brother and sister 
were attacked, in exactly the same way, a few days afterwards, 
although less formidably, and were cured by the same treatment. 
Shortly afterwards two of the servants got pain in the back of the 
head and stiffness of neck, followed by signs of an inflammatory 
affection of the cerebellum and spinal cord. They were treated in 
the same way, and recovered. 

What could be the cause of this peculiar fever, manifesting itself 
in exactly the same way in all the individuals of the family who 
were attacked ? I endeavoured to arrive at the cause, but could 
not; but I merely state thefacts, without wishing to attempt any- 
thing like an explanation. But the history of this extraordinary- 
form of disease is exactly as I have told you. It has been wit- 
nessed by Mr. King and Dr. Burke, and they, as well as myself, 
were very much struck with the novelty of the phenomena. 



LECTURE VI. 

Further remarks on the treatment of fever — Management of delirious patients — Ad- 
vantages of tartar emetic in the form of enema — Subsultus tendinum sometimes 
from disturbance of the nervous extremities, independently of the brain or spinal 
cord — Vomiting and purging at the commencement of fever, indicative of cerebral 
affection — Scrofulous inflammation of the brain — Chronic scrofulous fever. 

In speaking of the use of drinks in fever, I alluded to the abuse 
of soda or seltzer water, and effervescing draughts. It is very much 
the custom both in hospital and private practice, to look upon the 
latter as a remedy which may be administered at the pleasure of 
the patient, or the discretion of the nurse. They are certainly to 
many persons a most grateful means of cooling thirst ; but the 
cautious physician will never allow his patient to indulge too much, 
for he knows that their frequent use distends the stomach, and 
produces a tendency to tympanites and bowel complaint. I am 
also of opinion that the exhibition of large quantities of free car- 
bonic acid is a very doubtful, if not a dangerous, practice in fever, 
and may increase that tendency to narcottsm and functional de- 



296 G^; ^ - ^ ^ - LUHCAL LECriISE& 

raDg f : e :. : : ; ~ :_ 5 ?,:.:: r s : r atory systems, which is observed 

in e . z . : 1 £ e : re . : i : s . Irs ddition to this, the evolation 
of a -:^e ::i.. : riri .:; stomach frequently caoses a 

very : ; : ^ t : r : i s r : : : sieasion and suffocation, and acts in- 
juric'js.v ; :\ ;;.e ;..j:;:s :-.-. i :;. : r^oe. 

A e r r . : ^ f ; ; : : rrjcnt from my subject, and make 

a it : - 1 s : - terminated fatally in our wards 

wit: r : - . T I ~ ish to call yonr attention to 

this :'..iz : - . : ^- Cerent plan of treatment 

mig :. . It i : ri T : : ^ , i : :. *s life. This man was 
adfr.vi: .:.\: :> t t et t :h or eighth day of 

his t£: \ ::::.': :: : i r :; :reated in the com- 

ment t. \ y. \ r T - T : T : ?::: ltd, and that the 

stale ; r : : : r is s i .yiir^eit- T'willbesof- 

ficier. '.'. 5 e. e. t e ; ame under our c£ ; e .ief features 
of L 5 : ?- - e e : e ^ , : : r? ranied by totst waiii oi sleep, and 

a t: ; e : e : : e : : jr calling for the restraint of the 

stra : - s : : J r s : ances of this nature the most 

dili^T : : r : z : e imperatively demanded on 

the r e e : : :e calculated to anticipate 

dar. 3 e s : : . : . ; : y e ; . 1 re g : e: to say that I did not at 
the . - : arrect view of the treatment, or precautions neces- 

sary - ::ei 'joder such exigencies. I did not expect that 
the : : aate fatally in such a short time, and I antici- 

pate e e - e : e uedy prescribed. He was ordered to take 

the : z zv.: :.:-..: 3 in full doses ; but on visiting him next 

mc : . r e : : . . e ". d obstinately refused to lake his medi- 
cine, :. . . .-. 5 5 15 Trere greatly aggravated. 

In deiiriu::. :: i^ : ertainly very difficult to manage 

the patient, z e z e e e : b ^^ged to have recourse to force 
or stratagec. :: : e : . s edicines. 1 regret extremely 

that this ma:. 5 e ee : . ' "s admission, as, from the 

state of his p _ s e ^ e r e it well. Eight leeches 

might have l e . z e e e : : e cheated two or three 

times the sa ; e : : r e 5 : : . s pulse and strength. 

I think I was : r ^ - e : with ordering the tartar 

emetic solu::: ? i o.i.e: :. ;..£ ..c:^^. and 1 should have antici- 
pated fh>m : e : ence of bis behaviour that it would be very 
difficult to c : : r e r. . 

In cas^ : : ^ /rhere it is necessary to give tartar emetic, 

(and this is :;e : s remedies you can employ in cases of 

cerebral exc.e.e/. you should be always prepared to 

obviate any : : : z : : :i the obstinacy of the patient ; and 

when he wi.- : e ^ e e voluntarily, you may secure its 

ef^ts on ine syi.z./. ways. In the first place, it 

maybe sec:, y :e e ''? ordinary drink ; and as 

such person s ? e _ e e : : iom refuse drink alto- 

gether, an miemgeDl naiie wiii reaaiij find means to make the 



TREATMENT OF FEVER. 297 

patient take a sufficient quantity of it to secure its full effect on the 
cerebral circulation. 

Another expedient which you may resort to on similar emergen- 
cies, is to give the tartar emetic in the form of enema. I had re- 
course to this plan some time back, in a similar case of delirium, 
and with the best resulls. After leeching the head, I gave the solu- 
tion of tartarised antimony in enema ; and this can be always done, 
whether the patient likes it or not, if you take care to prevent his 
struggles by confining him in a strait waistcoat. The best way 
of administering it is to dissolve two or three grains of tartar 
emetic in four or five ounces of mucilage of starch or isinglass, 
and inject it with the aid of a long flexible tube, so as to make the 
contents of the syringe pass high up into the bowel. In this way 
you can secure all the good etfects of tartarised antimony in over- 
coming the congestion of the brain, and procuring sleep. In all 
cases of alarming congestion of the head in fever, I have been long 
in the habit of using tartar emetic in this way, if the stomach be 
deranged, and incapable of bearing it safely ; and I can assure you 
that it is a most fortunate thing to have such a powerful resource 
in all cases of the kind. I have also not unfrequently given expec- 
torant medicines in the same way, where from the state of the 
stomach, or the debility of the patient, the ordinary remedies could 
not be administered by the mouth with sufficient rapidity, or in 
sufficient quantity to produce the desired eflfect. In this way I have 
often given the infusion of ipecacuanha — a remedy of very consi- 
derable value, and not sufficiently appreciated by most modern 
practitioners. I may also remind you that vomiting, and all the 
benefits derivable from it, may be likewise produced, in this way. 
Now where the stomach is irritable, and yet there exists a necessity 
for such remedies, it is a very fortunate circumstance to be in pos- 
session of a means of employing them without inflicting any 
injury on the stomach, and thus counterbalancing the good effects 
of the remedy by the injury done to the stomach. Of course the 
cases in which these expedients are required are comparatively 
rare, but the practical physician must be always prepared for 
such exigencies, and be provided with every means of meeting 
them. 

Another of our patients died also within the last few days in the 
fever ward. He laboured under a very bad form of maculated 
fever, and when admitted was evidently in a hopeless state. I 
shall not say anything about this case, except to use it as an occa- 
sion for making a few observations on a particular state of the 
cerebro-spinal system, which we not unfrequently observe in cases 
of maculated typhus, and occasionally in other varieties of fever. 
Now you observed that this man had not the slightest tendency to 
sleep ; that he lay with his eyes constantly open, raved incessantly, 
had subsultus tendinum, floccitatio, and cold extremities, and often 
attempted to get out of bed. Yet we could not find in him any- 
thing like decided evidence of cerebral inflammation. The tunica 



298 GRAVES'S CLINKJAL LECTURES. 

adnata was of a clear pearl-white, the face pale, and the scalp and 

integuments of the face cool. You perceive, then, that sleepless- 
ness, delirium, and subsultus tendinum, may depend on a state of 
the nervous system having no connection with congestion of the 
brain, or determination of blood to the head. This occurrence has 
struck me very forcibly in many cases of fever. But I have been 
most particularly struck with the occurrence of subsultus tendinum 
in such instances. In the present case we had a patient with 
sleeplessness and subsultus. But this concurrence of symptoms 
does not always exist. You recollect the case of the boy in the 
small fever ward, who laboured under excessive subsultus, and to 
whom we gave the spirit of turpentine in dram doses with so much 
benefit. Yet this boy, as you all remember, slept remarkably well. 
I have frequently pointed out to the class patients labouring under 
subsultus tendinum, who slept well, and in whom the tunica adnata 
was of a pearl-white colour, without the slightest suffusion. We 
have subsultus, therefore, occurring in two very opposite states of 
the nervous system ; we have it accompanied with loss of sleep, 
and we have it existing in that condition of the system where the 
patient slumbers long and heavily, and cannot be easily roused. 
Hence I was inclined to think that the cause of subsultus resides 
not so much in the nervous centres as in their extremities. I would 
even go so far as lo advance the proposition, that if it were possible 
for the fever to go on, and life to continue after the removal of the 
brain and spinal cord, I am quite sure that the subsultus would con- 
tinue. I am almost confident that subsultus tendinum is the result 
of some derangement of the nervous extremities. I have shown on 
a former occasion, when lecturing on the subject of paralysis, that 
the nervous periphery may become diseased primarily, and without 
any antecedent affection of the brain or spinal cord. I think it 
extremely probable that in fever the nervous centres are subject to 
certain derangements producing coma, sleeplessness, and delirium, 
but that there are other nervous symptoms which are to be referred 
rather to a derangement of the nervous extremities, and among the 
latter I would particularly include subsultus tendinum, a symptom 
which we find co-existing with such opposite conditions of the 
nervous centres. 

But to return to the case to which I first alluded. Never blister 
in the early stages of fever, until you have applied leeches in sufH- 
cient quantity. In this case, it is true, we could not well ascertain 
w^hat the period of the fever was ; for the man was brought in in 
a state of delirium, and there was nothing known respecting his 
previous history. Yet you are all aware that a great deal must 
depend on our knowledge of the period of the fever, and the medi- 
cines which have been employed. Had we been acquainted with 
these circumstances, it is probable we would not have fallen into 
the error we committed. What I wish to impress on you, is, that 
in all cases of maculated typhus, you should be careful in examin- 
ing the head and ascertaining whether there are any evidences of 



TREATMENT OF FEVER. 299 

cerebral congestion present. If there is headache, strong pulsation 
of the carotids, suffusion of the eyes, and heat of the face and 
scalp, along with the other signs of functional lesion of the brain 
present, you should always have recourse to leeching; beginning 
cautiously, and continuing their application as long as the patient 
will bear it with safety. When you have the symptoms already 
mentioned, and the patient is in the early stage of fever, you may 
commence by applying one or two leeches to the nostrils, or six or 
eight to the temples, or behind the ears, repeating them two or 
three times a day, according to the exigency of the case. The best 
way of using leeches is to apply them in small numbers every six 
or eight hours, so as to keep up a constant drain from the head. 
After you have leeched sufficiently, you may then have recourse 
to blisters. In making this change, much will depend on the saga* 
city and skill of the practitioner; for it requires no ordinary tact to 
hit on the proper time when you should give up leeching and com- 
mence with bhsters. 

I shall make no apology for introducing here what I consider to 
be an important observation, with reference to the pathology and 
treatment of fever. We had a striking instance of the fact on 
which I am about to offer some comments, in the case of a little 
girl who died lately here, in a very remarkable manner. T men- 
tioned in a former lec);ure, that vomiting and purging in the com- 
mencement of fever are, generally speaking, indicative of a cerebral 
affection. Every fever which commences with vomiting and 
diarrhoea, whether it be scarlatina, or measles, or typhus, is a fever 
of a threatening aspect ; and in all such fevers the practitioner 
should be constantly on the watch, and pay the most unremitting 
attention to the state of the brain. There is much difference be- 
tween the vomiting and diarrhoea of gastro-enteritis and this cere- 
bral diarrhoga and vomiting. The latter sets in generally at a very 
early period of the disease, perhaps on the first or second day, and 
is seldom accompanied by the red and furred tongue, the bitter 
taste of the mouth, the burning thirst, and the epigastric tender- 
ness, which belong to gastro-enteric inflammation. There is also 
another source of diagnosis, but of a less valuable kind ; and this 
is founded on the results of treatment. Gastro-enteric vomiting 
and diarrhoea are relieved by leeching the belly; but I need not 
tell you that this mode of treatment can have no effect on the 
vomiting and purging produced by cerebral disease. There is also 
another source of diagnosis ; the vomiting and diarrhcea which 
results from gastro-enteric inflammation is never accompanied by 
such copious discharges of bile as that which depends on disease 
of the brain. In diarrhoea from derangement of the brain, the 
quantity of bile passed is very remarkable ; and it is equally cu- 
rious, that when vomiting follows derangement of the cerebral 
circulation, in ordinary cases, and without fever, bile is thrown up 
in very large quantities. This is frequently observed in persons 
who become sick from swinging, or sailing. In such instances, a 



300 GRAVESrS CLES1CAL LECTUKES. 

larger qoaatity of Inle is vomited than cooid occur fFOtn mere gas- 
tric irritation. !Now in the cofflmeDceiDeDt of cerebral disease, 
where congestion or inflammation is present, one of the first symp- 
toms is copioDs vomiting, and porgii^ of a Inlioiis character. 
This is very often the case in scarJatina, and there are few cases in 
which there is more danger to be apprehended. We had these 
symptoms, under very unfavoorable circumstances in the litiie 
girl to whom I have jost alloded. From the impenect history of 
the case which we were abie to obtain, it appeared that die bad 
been ill of fever for fourteen days before her adniis»on, and had in 
addition a severe attack of bronchitis and pnemnooia. She then 
got inflammation of the stomach, and finally cong^tion of the 
brain, as indicated by the cerebral vomiting and pnrgiDg. We 
employed every means in our power to check these symptoms, but 
without success ; she went on from bad to worse, and she ulti- 
mately sank under a combination of aflectioos, which yon will 
frequently observe in many forms of disease as weil as in fever; 
and it is to this point in particalar that I wish to direct your atten- 
tion. You will fr^oently observe that at a certain period of fever. 
whether it be inflammatory, nervous, bilious, or typbiii. — 2^r.: 
very often in other forms of disease, whether dee-^-^-r " : ZTir- 
ral auction of the system, or connected vr r 

important organs, when the patient has berai r i t 

for sometime, — yon will find that about the pe: i 

naturally expect that the fever wonld go c f : r 

begin, a new form of fever makes its appear r : _ : : ii :d 
the patient in spite of all your exertions. 7 r :orm of second- 
ary fever I would give the name of scrci 
Wes in its chief features the intractable 
frequently observed in persons of r :t 

who have become so from tbe a : f ii- 

ing causes. This is a form of fever t : d. 

and I am not acquainted wirh ehv z_ : :: it 

that share jof attention to w v. its great in i. it has 

such decided claims.* Its c...^: c.^racie^s ?"t ----'eni, 

during its existence, exhibits a strong U: i : -y 



? fever-Tsrhic: 



soia^iiiieB is m^ '^ 

of the 5TJ 7 : _ --nanies a : 



.1 10 :r. -^ 

roliar =t^ 
"ci Ed.', 



TREATMENT OF FEVER. 301 

affections, which bear a close analogy to the scrot''ulous, both in 
their intractable character, in the facility with which they pass 
from one organ to another, and in their frequently unfavourable 
termination. A patient of this description, while labouring under 
fever, will frequently exhibit a very remarkable succession of in- 
flammatory affections. If, during the course of his fever, he gets 
an attack of gastro-enteritis, you will have great difficulty in 
managing it ; and no sooner is this overcome, than he is seized 
with bronchitis or pneumonia ; and when, by great care and the 
most skilful treatment, you have overcome this also, he gets scro- 
fulous inflammation of the brain, and dies. Now you will fre- 
quently meet with patients who, during the course of typhus, will 
be attacked with this bad form of fever, and get what may be 
termed scrot^ulous inflammation of the brain, which carries them 
off" in five or six days, in spite of all your care. You are aware 
that persons who are much in the habit of observing disease of the 
brain, can generally distinguish between scrofulous inffammation 
of the brain and its metnbranes and that inflammation which occurs 
in persons of healthy habit. In cases of the latter description, the 
treatment, if commenced at the first appearance of the disease, is 
simple and successful. Appropriate bleeding and leeching, with 
the use of calomel and James's powder, are almost always suffi- 
cient to accomplish a cure. When once you have succeeded in 
touching the gums with mercury, the patient's safety is tolerably 
certain, and recovery is in general rapid; but in the scrofulous 
afl?ections of the brain, although you may have fully mercurialised 
your patient, you will too often discover that you have merely 
retarded the progress of the complaint for a brief period ; it returns 
again, and carries him off* in spite of all your efforts. In the 
scrofulous hydrocephalus, a much greater time elapses from the 
appearance of coma and strabismus until death takes place, than in 
the ordinary forms of meningitis. This fact was well illustrated 
in the case of the little girl to which I have just now referred : she 
continued to live on for a long time after the appearance of symp- 
toms which you would think ought to terminate fatally in a few 
hours after they had become developed. There is also a great deal 
of irregularity in the way the symptosns come on in cases of scro- 
fulous inflammation of the brain. Sometimes blindness is one of 
the first symptoms. I recollect having been called, with Dr. 
Beatty, to see a very fine boy, living in Merrion square, and was 
very much struck, on entering the drawing-room, to find him 
walking about, and in apparent good health, but quite blind. 
Here amaurosis was the first symptom. This was subsequently 
succeeded by others, and he died in a convulsive fit about a fort- 
night afterwards. 

We have many excellent observations on the chronic scrofulous 
fever, but I think that there is no author who has described this 
acute form with the precision and care which it deserves. It is, 
however, a very frequent form of fever, and vou will see many 

26 



302 GRAVES'S CLINICAL LECTURES. 

examples of it among the chronic patients in the medical and sur- 
gical wards. You will frequently observe persons who are labour- 
ing under acute disease, from accidents or other causes, become 
feverish and ill again at a time when you expected a remission of 
their symptoms, or even recovery ; and, without any assignable 
cause, they will get scrofulous inflammation of some other part 
or organ, and quickly fall into a state of hopeless and incurable 
disease. 



LECTURE VII. 

Scarlatina without eruption, followed notwithstanding by desquamation — Thoughts 
on the nature of desquamation — Latent scarlatina, followed by anasarca — General 
proposition respecting the symptoms of animal poison — Morbid appearances after 
delirium in fever — Treatment in anticipation of cerebral symptoms — Great advan- 
tage of blisters judiciously employed — Notice of the old mode of blistering. 

Before I resume the thread of my discourse, permit me to men- 
tion some curious facts recently observed. Dr. Marsh and I 
attended, not long since, a lady who had been afl?ected for some 
days with fever and sore throat. She had no eruption on any part 
of her body, but from the character of the fever, and the peculiar 
appearance of the throat, we suspected she was labouring under an 
attack of scarlatina. Her family were very anxious to ascertain the 
precise nature of her complaint; and I visited her twice a day for 
the first four or five days of her illness, carefully examining the 
skin at each visit, but could not discover the slightest trace of an 
efflorescence of any description. She continued for several days to 
suffer from the fever and sore throat, and was at one time in a dan- 
gerous condition, but ultimately recovered by great care and the 
use of appropriate remedies. Now I watched this case from the 
sixth hour after its commencement to its termination, and repeat- 
edly examined the skin, particularly that of the breast, abdomen, 
and inside of the knee and elbow joints, places in which the erup- 
tion shows itself w^hen it appears at all, but could not discover any 
vestige of it. You will often find a difl^used redness about the 
knees and elbows, in cases where the eruption does not appear on 
any other part of the body ; but in this instance there was not the 
slightest deviation from the natural hue. Yet the result proved 
that it was scarlatina; for the desquamation of the cuticle, which 
always attends this disease, took place, and the lady communicated 
the infection to several members of the family. A young gentle- 
man residing in the house got a bad attack of scarlatina, two of the 
servants were also attacked, and the lady's father got sore throat; 
in fact, there could be no doubt as to the nature of the disease. 
During her convalescence she had desquamation of the cuticle ; 
and this is a point to which I would particularly call your atten- 
tion. We are taught to look upon desquamation as the result of 



TREATMENT OF FEVER. - 303 

cutaneous affections of an inflammatory character ; and it is an 
opinion very generally maintained, tfiat in scarlatina, as in psoriasis, 
the peeling off of the cuticle depends on a peculiar state of the skin 
produced by inflammation. It is stated that the increased vascu- 
larity of the skin occasions a morbid secretion, and subsequent 
detachment of the epidermis, and that the same phenomenon is 
observed in all cutaneous affections of an inflammatory character. 
This may be generally, but not universally, true ; for here we had 
an extensive desquamation of the cuticle without any eruption, 
without any previous redness, pain, or remarkable heat ; in fact, 
without any of the phenomena which are regarded as constituting 
inflammation. This seems to prove that there is something more 
than inflammation concerned, as preparatory to that process which 
is termed desquamation, and that the change which the skin under- 
goes is not to be looked upon as a mere consequence of inflamma- 
tion occupying the external surface of the corium. 

Another curious fact observed in this lady's case : since the 
attack which 1 have just described she has been shedding her 
nails ; that is to say, the nails of the fingers are all dropping off, 
and yet there is no appearance of inflammation of any kind about 
the hands to explain the occurrence. You are, of course, all aware 
that the dropping off of the nails is a species of desquamation. 
From the peculiar structure of the nail, and the mode in which it 
is formed in the matrix, it does not drop off at once like a scale of 
epidermis; still I think we are authorised in looking upon the 
shedding of the nails as a species of desquamation. This affords 
a very curious subject for investigation, as connected with the his- 
tory of fever. It is an opinion entertained by many persons, that 
desquamation of the skin takes place at a particular period of typhus, 
and that this is not an occasional, or varying, but a constant and 
general phenomenon. This statement has been put forward most 
strongly by Dr. Perry, of Glasgow; and he is also of opinion, that 
the period in which typhus is most contagious is during the des- 
quamation of the cuticle. It is also asserted, that scarlatina is more 
contagious during desquamation than at any other period of the 
disease. This is at least the popular idea; how true it may be my 
experience or observation does not enable me to decide ; nor am I 
prepared to offer anything like an explanation of the occurrence. 
All I shall say on the present occasion is, that the occurrence of 
desquamation of the cuticle in typhus, and in cases of scarlatina 
without eruption, has greatly altered my ideas as to the connection 
between it and cutaneous inflammation. I think, at least, that the 
process of desquamation in such cases is very different frop inflam- 
mation, and that the morbid action of which desquamation is the 
result, has very little in common with the ordinary process of in- 
flammation of the cutaneous surface. 

A gentleman who is in the habit of attending my lectures informs 
me that he has seen three cases of this form of scarlatina, character- 
ised by the absence of the external efflorescence. They occurred 



301 GRAYEST CXUnCAI. LECnURES. 

in joumg. personsy after pobertj, and between the ag^ of fifteen and 
twentjF'-fiv^ £a€:li of Usese casss exhibified a considerable degree of 
fev€3-, wiih increased qnickne^ of pok^ tbirst, heat of skio, dimi- 
noEicMi of tfae nrioarf %cretion« and, after the first or second day. 
moch depres^€>n, whicb coBtiDiied for Hwo or three days, aod then 
yielded to treatmenL The toDgoe was osoist, bat pointed, trema- 
los^ Ted, and injected. The feiom, istfamus faaciiiim* toosils^ and 
nipper part of tbe pharynx, were somewhat swollen, aod of a very 
pecidiar dark-red coionr, Ibe redness beii% general, and equally* 
ififibsed over tbe wbc^ of the upper part of the pharynx as far as 
it C€Ndd be examined. Bnt tbe Ibllowing ease, which was Tery 
lately communicated to me by a practitioner of very great eminence 
in thib erity, is still more corieos. Some years ago scarlatina broke 
oat in th^ gentleman's faoiiiy, and attacked alt his children- with 
the ex«:eption of»one yoang lady, who, althocgh ia constant attend- 
ance cm her sisters disring their illness^ did not exhibit any synap- 
toms whatsoever of the disea^L When ail the children had become 
convalescents they were remofed to the ccmntry for the benefit of 
air, whither she ako accompanied them. Here she was, much to 
the astonishment of her family^ attacked by the pecnliar anasarca 
observe in per^ms who have recently laboured onder scarlatina. 
Her ftitheTy nn^ whose observation she had been daring the whole 
time, was very moch stmck with tbe occorrence; he paid particQ- 
lar attention to the case, and feels convinced that it was the resnlt 
of latent scarlatina. This case, cuinnected with those already 
detailed, is of great interest in a general patholc^ical point cf view.^ 
They appear to prove the fact, that ia some instances diseases pro- 
doced by contagicm do not give rise to ike whole train of pheno- 
mena by which they are ordinarily characterized. 

Let OS torn for a nMHneot to some of those diseases caused by 
the action of animal poisons on the system, as, for instan<:e, measles. 
The symptoms which generally attend and characterise measles 
are oEiiversally known. After an attack of fever, on the third or 
foortb day, coryza, snee^n^, hoarseness, aEid cough, are complained 
o^ and then a rash appears, first on the face, and afterwards on the 
body and limbs. Bat it is not necessary that all these symptoms 
Arnold appear, and that the sequence of morbid phenomena shoald 
be Dninterrapted throogboat; on the contrary, it frequently hap- 
p^is at pertic:alar permds, and in certain constitotions, that some 
of the most n^ial symptcmis are scarcely observed, or altc^ether 
absenL Yoa will find this point insisted on by Dr. Bateman, who 
has given a detailed description of a form of measles in which the 
<»tarrhaL symptoms are wan tis^ and which he has termed mbeola 
sine cuitarrho. The same remark apfdies to many other forms of 
disease. Thos we may have pneumonia without cough, and pleii- 
litis without pain in the 5 f= "[Hiose who have witnessed the 

"^ flm may cf flseae iiseasesmtme c^tlie ^pnpiaias are sb^at; bat iBBOoe so 



TREATMENT OF FEVER. 305 

course of the late epidemic cholera in this country, will recollect 
that many cases occurred in which vomiting, purging, or cramps 
were not observed. 

If we turn to fever, we find that the animal poison to which it 
owes its origin generally exhibits a certain number of symptoms, 
congregated together, or observing a determined order and succes- 
sion : and these we meet with in most of the cases which come 
before us in practice. But we now and then see fever patients in 
whom one or more of the most prominent symptoms are absent. 
Thus occasionally there is no quickness of pulse or appearance of 
vascular excitement; in some there are no cerebral symptoms; in 
others no increase in the temperature of the skin. Indeed, I might 
go through the whole group of symptoms which accompany fever, 
and show that almost every one of them may be occasionally 
absent, and yet the fever of a severe and dangerous type, I recol- 
lect pointing out to the class last year the case of a man labouring 
under chronic enlargement of the spleen. He had been working 
for two or three seasons in some of the marshy districts of England, 
and had been occasionally ill, but never had symptoms of regular 
intermittent; in fact, he had escaped the intermittent itself, but not 
what are usually deemed the consequences of it. We have been 
in the habit of explaining the enlargement of the spleen by refer- 
ring it to the conflux of blood towards the internal organs, particu- 
larly the liver and spleen, during the cold stage of intermittent; 
and we have endeavoured to explain the subcutaneous oedema 
which follows scarlatina, by attributing it to previous inflammation 
of the skin and subcutaneous cellular tissue ; but the observations 
and facts which I have now brought forward will show that these 
opinions were founded on erroneous ideas. Turning to cases of 
chronic disease, we find in some, as for instance syphilis, that the 
poison taken into the system gives rise in most cases to a determi- 
nate order of symptoms, e. g. bubo, sore throat, eruptions on the 
skin, nodes, and syphilitic cachexy. Mr. Hunter has been at great 
pains in determining the order of the parts, and pointing out the 
tissues which are successively affected, and it is of considerable 
importance to have correct notions on this point ; but although the 
number and order of symptoms marked out by Mr. Hunter and 
others may be observed in most cases, they are not so in all; and 
the same remark which has been made on the occasional absence 
of one or more important symptoms in scarlatina will apply with 
equal force to syphilis. Now and then the morbid poison which 
excites syphilis does not affect the constitution in such a manner 
as to occasion the production of all the symptoms which usually 
characterise this disease, and thus a variety of venereal is formed, 
which often proves a source of great embarrassment not only to 
the young and inexperienced, but even to the senior members of 
the profession. 

It is of great consequence in a practical point of view, to bear in 
mind the general proposition I have announced, viz., that in both 

26* 



306 GRAVES'S CLINICAL LECTURES. 

acute and chronic diseases a constitutional affection ?nay display 
its existence by only one or two of the numerous sympioms which 
usually accompany it; and this occurrence seems more frequent in 
the case of diseases produced by contagion and morbid anirnal or 
vegetable poisons, than in the case of maladies generated by causes 
developed in the system itself. 

I spoke at my last lecture of a man named Cassels, 'U'ho died in 
the fever ward with symptoms of cerebral excitement, and stated 
that I regretted having omitted to leech his head, and prescribe 
tartar emetic in the form of enema. Since that time we have had 
an opportunity of examining his body, and the results of the dis- 
section are well worthy your attentive consideration. He was a 
young man of robust habit and apparently good constitution, and 
laboured under the ordinary form of maculated typhus. Shortly 
after his admission he was attacked with delirium, which was soon 
afterwards followed by coma and death. Now, suppose you were 
called to see a patient, not labouring under typhus, but exhibiting 
a similar train of symptoms, — that is to say, violent delirium, 
accompanied by flushing of the face, suffusion of the eyes, head- 
ache, and a tendency to get out of bed — in fact, a state of furious 
excitement requiring the restraint of the strait waistcoat, — what 
idea would you be lii^ely to form of the condition of the brain 1 If 
a patient of this kind had no typhoid symptoms, you would cer- 
tainly say that he was labouring under meningitis or cerebritis; 
and if the case proved fatal, you would naturally expect to find 
lesions of the brain fully sufficient to account for all his symptoms. 
And you would in all probability find extensive thickening of the 
nnembranes of the brain, with subarachnoid effusion, or you would 
discover softening, increased vascularity, and suppuration of the 
encephalic mass. But, here, a man in fever exhibits all the symp- 
toms of cerebral inflammation : the cerebral affection runs on to a 
fatal termination with great rapidity ; he dies comatose. And what 
do we find on dissection ? Doubtful signs of congestion, and no 
distinct evidence of inflammation; a slight opacity of the arach- 
noid at the base of the br^in,and about a teaspoonful of clear sub- 
arachnoid effusion. Now this is a point to which I would earnestly 
call the attention of everv inquiring student. A patient, during 
the course of typhus, is seized with symptoms which are generally 
regarded as characteristic of congestion and inflammation of the 
brain : he dies, to all appearance in consequence of the intensity 
and violence of these symptoms, and on dissection little or no trace 
of cerebral disease is found. In the case under consideration, the 
symptoms present were strongly indicative of congestion if not of 
inflammation ; and had the man been free from typhoid symptoms, 
you would expect to find decided traces of inflammatory mischief. 
This seems to prove that in the production of cerebral symptoms 
in typhus, some cause not to be recognised by the production of 
cerebral lesions, or in other words something besides mere conges- 
tion or inflammation exists. I have now examined a great number 



TREATMENT OF FEVER. 307 

of cases of this description, and the examination has brought home 
to me a strong conviction, that the dehrium of fever depends upoa 
something more than mere inflammation or congestion. There is 
another fact, the study of which is well worthy of attention, as it 
appears to support very strongly the views I have put forward ; 
and this is the occurrence of analogous symptoms under opposite 
conditions of the cerebral circulation. Take, for example, the phe- 
nomena of vertigo and headache. Now these symptoms are found 
in states of the brain which are directly opposite. In incipient con- 
gestion of the brain, in that turgescence of the cerebral vessels 
which precedes apoplectic seizures, one of the most frequent symp- 
toms is vertigo, and the same thing may be affirmed with respect 
to lieadache. But we observe the very same symptoms under cir- 
cumstances totally dissimilar. Frequently while bleeding a patient 
for some affection of the lungs or bowels, or for some accident, we 
find that after a certain quantity of blood has been lost, the patient 
becomes pale; and while the pallor is coming on, he often gets 
quite giddy, and sometimes complains of headache. Gentlemen 
who are attending lying-in hospitals are well acquainted w^ith the 
headache, giddiness, and tinnitus aurium, so constantly complained 
of by females who have suffered from excessive uterine hemor- 
rhage. Hence you perceive facts are not wanting to show that 
opposite states of the cerebral circulation, a superabundance or 
deficiency of pressure on the brain, may give rise to similar pheno- 
mena. You saw an illustration of this in the case of one of our 
patients in the fever ward this morning. He was quite free from 
headache as long as he remained in the horizontal posture, but the 
moment he sat up in bed he cotnplained of headache. Yet this 
was a man who had not the slightest symptom of determination to 
the head, and who had been sufficiently depleted during his illness. 
You will also recollect the fiict, that persons who have had a long 
illness, and remained for many days in the horizontal posture, 
generally get weakness, giddiness, and sometimes headache, at first 
when they attempt to sit up during convalescence. This is a point 
which should always bo borne in mind. You are consulted by 
one person who complains of giddiness, tinnitus aurium, and fre- 
quently recurring headache. You examine the patient carefully, 
and you find all the symptoms of unequivocal determination to the 
head. You are applied to by another person labouring under the 
same symptoms; but how different is the state of the brain found 
to be on a careful examination. One patient is robust, of florid 
complexion, and with a hard bounding pulse; the other is a weak 
chlorotic female, who has been ailing for months, and whose pulse 
is so w-eak, that a slight degree of pressure obliterates the canal of 
the artery. Yet the tinnitus aurium, giddiness, and headache, 
complained of by the latter, is just as bad and as troublesome as in 
the case of the former. 

From a consideration of these points, you will perceive that, for 
the production of cerebral symptoms in typhus, there must be 



303 GSATESrs CLUnrCAL, I£CmME& 

somethii^ more than mere concession or inlfommafion of the 
brain ; but yoo are not to infer firora this i':. :■.: ' t^ T^essity 

for taking any steps to obiiate or remoi^e c : i^ 7 5 e^d in 

fever- fii the conlrairy, I am of (pinion that : :ie 

piincipaT soQTces of dan^r is c:<mnected will:: t t?. ; :it 

the cefdbral symptoms should be always watched with the most 
Qnremitting and anxioos attention. It is this whicth. constitotes 
the great di&ience between the mortality in piii^te and hospital 
^actice^ In priiate pracitice the physician is <:a11ed at an eaiij 
period of the di!P??«e. 9^ has an iippoftoifiif y «f checking the cere- 
bral syrj : • ; :T5 '-; t tt rise to 2 zi: z^ ' 7 rit; bat hospital 
patienli«. ,:;. r^ : i 7 : isii"*=d 1: ::.::: - 7 ■ ze cf fewer, and 
in many ins: f : 7 : ^ 7 neglected 
from the cc : 7 r - ^Ibeie is 

any evidenc 7 . : . : -■;•.• 7 i ^ 77; : ^ rsvent- 

ing d&zzz : : : J r : ^.' = e 777 i . 7 ^ :"'.:.=: 

appSics:. ; ; : : v 7 . 7 : ; 7 i i :: : 7 : ; : : : 7 7 _ 

to tine "..' \ _ ; 5 : : : 7 ' : " 7 ■; : : . : 5 iHLiicia 

to the h - _ . 7 _ ; ■ 7 _ =, 1 ::. : : ;vr ; i 7 : ; : : 7 5 : :' doifig" 

this is -. . ■:■ SB«: or eight iee: 75 77- _ repeat 

them e' 7 ; ;: '^':^"3rs ontil relie:' 7. V .. i ilhsen 

order ::. : / : : _ :<s shaved, at : ^ : : 7 7 i with 

clolfas^7; -" :t — aegar ar: • : 7 ? : - : i *::iac 

hai^ ic : - — : i . 7 nial ose : :' : ' ; : : i ; ;.:::.: iG 

pill, wi : ;_ V ■ - 7 ; : "^ ^. ::':■:. e : .^ik t^ m gkVk^ . i . i ' 

y«in hs : - of blisters to the 5: 

and this " . ; 7 .7 7~ i ;: i ■. ■ -; ;: rnceu 
' illos: : : .7 ;' ^ : "7: : : " : .:e : : ~ 7-7" : .^"eof cerebraldisr^s-e. 
Bet in : 7 : :: ; lat these were :57s 

in 'whi:.. 7 7:„. "^ :. 5 .. 7r 7:7;., . . '" ~ ^-': the ai^rc'pEiaLe 

•lemedif : 7 if ihe commence- 

ment w.::. -j:^ 7 • : i : : : .; 7 ::'. "'7 -7^d 

may be : •. :r 7 : t 1 7 ■..:..;- 7 : : 7 ■ - i : - i ; ; :' ; : 7 " -^ 

observe: .:. ::.i^ :::'ii "7:7 -..t 7:.- - 7 - :: 7 ;: 

symptom" ^ . :3 :;; 77:. : ;; ; :"i ; : . : ' > 7 . 7 :; :.:7 " ?; ::£:£ 
i^fcere:. - :5i:;7"': :...: i -.;::•:: ; : ;• :. : ::?, and 

which V : ./ 1 ~ ?. ^ ":::;• ; : • 7 ; 7:7 ' i sevenlh 

day, 1=1 • "■ : : : 5 ' ; . . " : . ^ _ . Z : :. ' 7 : ; 5 : 1 se was 

saved iy ::::■:: : . : ii;.:!: -7^:. 7: :: :i!eract 

the cerT . fv ;:::; [ '-7 ::: : -\^ - .. - ^..^ a»- 
otlier Yi ^ : : : 2 

Tbe :: i / :, - 7 .-- -.7-7 : ^ . : ^ -'iaMy 
teir ■; 7 - : ; i : ^- 7 :. ■ . ; v - r ■ : , -:-:■ : £ : ; ■ ~ : . 7 . : 7 7 ■-;:;::: ; - . : ; 7 
inle:.£72- -\:_7-_: -_,:.;; :;:._ fivc^. .'v^ ,.L^.:.a >^: 7. . :„■: :: : :. 1^:^*6 
na: : 7 7 " : ^ ~ him in consolta: _ iJefer- 
nat :" : .7 ~:: . ::;■ -{5 ; 7: :i:?]ie had fce7::. ;7 7-7: 7 77: -'12. 
be: :.-£ ::-:: :.-"r -'s -zr/ :;.:£:. and br ■":£ : .:;£: :::i-'r:.y 
asle7:, ^:;::'. -7 ; .::: i;-? £:-7"-"--- 5,.r\fi;. ^ ^ 
crt: .:" :.■.::_. I7, "V^ ::; :.-.:i : .,;-;-_ ; .t --..;.- ,:i 



TREATMENT OF FEVER. 309 

the eighth day blistered it again, and also the nape. On the ninth 
day the cerebral symptoms, which ice had been endeavouriiig to 
anticipate came on, but probably our treatment prevented them 
from being fatal ; for when ihey appeared, the application of tartar 
emetic ointment induced a purulent discharge from the whole sur- 
face of the twice blistered scalp, in the course of a few hours, and 
three grains of tartar emetic given in divided doses that day pro- 
cured a complete cessation of the symptoms, after — mark, after 
— the pupils had been dilated, and one fit of slight paralysis of the 
mouth and tongue had taken place. 

The result of all my experience in fever is, that the majority of 
fatal cases are rendered so, in this country at least, by severe cere- 
bral symptoms supervening sooner or later in the disease. Deli- 
rium, sleeplessness, stupor, convulsions, extreme subsultus, jactita- 
tion, sluggish and dilated, or else extremely contracted, pupils; 
these are the symptoms we have to fear after the fever has lasted 
some time ; and let me repeat it, the chief art of the physician con- 
sists not so much in remedying these symptoms as in anticipating 
them. When he judiciously attempts this, he may not, indeed, 
always succeed in altogether preventing their supervention, but he 
will, in the great majority of cases, be successful in diminishing 
their violence, and preventing their usual disastrous effects. 

I shall now resume the subject of blistering in fever, on which I 
made some observations in my last lecture. I have spoken of it 
chiefly as a powerful revulsive remedy in the treatment of cerebral 
congestion ; let us now treat of its employment with other objects 
in view. In the first place, as has been already explained, blisters 
may be used as most energetic stimulants in cases where the 
powers of life flag, and threaten a sudden cessation. Occasionally, 
in fever, you will find the vital tone reduced to a very low pitch, 
the heart uncertain in its action, the pulse irregular, the respiration 
feeble, the skin cool, and the patient so weak that he cannot be 
lifted up, or even turned in bed, without having a tendency to faint. 
Here we have to superadd to the ordinary treatment of fever the 
prompt exhibition of remedies calculated to meet such emergencies, 
and in addition to internal stimulants, we have recourse to power- 
ful stimulation of the cutaneous surface by what are termed flying 
blisters. One of the best remedies in such cases is a large blister 
applied over the region of the heart, to be left on for two or three 
hours, or until the vascular action of the skin is sufficiently excited. 
When the patient appears to labour not only under sudden weak- 
ness of the heart, but also of the capillary and nervous systems, as 
shown by coldness of the extremities and sinking of the pulse, it 
will be necessary to apply flying blisters, not only over the region 
of the heart, but also over various parts of the chest, the epigas- 
trium, and the inside of the legs and thighs. You will find this 
plan of treatment frequently succeed in cases which have a very 
unpromising aspect. I have now witnessed many instances of this 
description, in which, from cold, neglect, or debilitating treatment, 



310 GRAVES'S CLINICAL LECTURES. 

the patients appeared moribund, with lividity of the extremities, 
hippocratic face, cold skin, and failing pulse: *and I have seen them 
saved, as it were miraculously, by the use of carbonate of ammonia, 
musk and wine, and the application of warm fomentations to the 
limbs, followed by a succession of flying blisters. 

The next use to which w^e apply blisters is in the treatment of 
those pulmonary afl^ections which arise during the course of typhus. 
From what you have seen of the present epidemic, you must be 
convinced that bronchitis is one of its most frequent compUcations, 
and that few patients pass through fever without having some 
affection of the bronchial mucous membrane. You are also aware, 
that when bronchitis attacks the more minute ramifications of the 
bronchial tubes, it is very apt to produce congestion and engorge- 
ment of the lung. We meet with pneumonia much less frequently 
in fever, but it is occasionally observed, and requires the most 
prompt and decided treatment. In pneumonia, as well as in con- 
gestion of the lungs, accompanied by inflammation of the smaller 
bronchial tubes, blisters afford us a 'most valuable adjunct to the 
other means which we emplov, and admit of being used in cases 
where no other mode of depletion could be safely borne. The 
affections of the lung in fever are of no small importance, and the 
stethoscope has not conferred a greater benefit on practical medi- 
cine, than by indicating, in diseases of the chest, not merely the 
existence of disease, but also its locality, extent, and precise nature. 
It points out to us the portion of the chest in which the bronchial 
tubes are chiefly engaged, and informs us with certainty when the 
aflection of the smaller tubes and air-cells has given rise to pulmo- 
nary engorgement. The experienced stethoscopist will in such 
cases be aware of the exact site and nature of the affection, where 
the mere symptomatic practitioner would be unable to acquire any- 
thing more than a loose and undefined notion of pulmonary dis- 
ease. The latter employs his depleting means at random, and fre- 
quently abstracts a large quantity of blood with little benefit to his 
patient; the former, aware of the exact situation and extent of the ^ 
disease, applies his leeches or cupping-glasses immediately over the 
engorged or inflamed portion of the lung, and relieves his patient 
at the expense of a comparatively small loss of blood. The same 
observation will apply, with equal force to the use and application 
of blisters. A srood and accurate knowledge of the various stetho- 
scopic phenomena is besides of so much more value in the treat- 
ment of fever, as, at certain seasons of the year, almost every case 
of fever will be complicated with pulmonary derangement ; and it 
may happen, during the course of an epidemic, that the lungs may 
be the organs which are chieflv engaged. Although cerebral dis- 
ease is at present the principal source of danger in lever, it may not 
be so always. A change may take place in the character of the 
epidemic ; the cerebral symptoms which are now of such frequent 
occurrence may become infrequent or inconsequential, and we may 
have the organic afiections chiefly limited to the viscera of the 



TREATMENT OF FEVER. 311 

thorax. I have seen many cases of fever in which the principal 
source of danger was connected with the chest, and where an 
accurate knowledge of the stethoscope was indispensable to a cor- 
rect and successful phin of treatment. 

jVovv when you have recourse to blisters in treating pulmonary 
affections, whether these affections be simple or complicated with 
typhus, it would be well to recollect that much good may be effected 
without leaving the blisters on for a long time, or until they rise 
fully; and also that when risen, it will not be necessary to cut 
them at once and let out the effused serum. In treating the bron- 
chitis of children, and in the bronchial affections of fever, I have 
li-equently directed the blister to be left unopened ; and I can state, 
Irom experience, that this plan answers very well. The effused 
serum forms one of the best dressings for the excoriated surface of 
the skin, and the formation of troublesome sores is avoided. I fre- 
quently have recourse to this mode of treating blistered surfaces in 
children, and persons of irritable habit, in whom the cutis is ex- 
tremely tender and vascular. Such persons, when blistered, will 
often have profuse discharges, first of serum and afterwards of sero- 
purulent matter, from the denuded surface, accompanied by tortur- 
ing pain, loss of rest, and considerable irritation of the general sys- 
tem. I have seen the discharge continue to flow profusely for fiive, 
or six days ; in fact, to such an extent as to wet several napkins in 
the course of a day, and expose the patient to the risk of an aggra- 
vation of the pulmonary symptoms, in consequence of his linen 
becoming so frequently moistened as to require repeated shifting.* 
In all cases of children and persons of an irritable habit, I would 
therefore advise you to let the blisters alone, particularly where 
they have been applied to the fore part of the chest, or any other 
part not exposed to pressure or friction. As soon as the blister 
rises, apply over it a piece of lint, smeared with spermaceti oint- 
ment, which can be renewed as occasion requires, and leave the 
rest to nature. I was forcibly struck some time since, with the 
difference of result between this and the ordinary practice, in the 
case of a young gentleman residing in Cambden street, who had a 
severe attack of bronchitis towards the termination of fever. A 
blister had been applied to his chest in the morning, and another 
in the middle of the day. The first had been opened freely, and 
dressed in the usual way ; but the other, which had risen 'about 
the time I was called in, was left untouched at my request. The 
one which had been opened caused such a degree of irritation and 
restlessness, that it was found necessary to give him an opiate every 
night; the other gave little or no inconvenience, and healed up much 
sooner. If I have done nothing better, I think I deserve some merit 
for being the first to reprobate the practice of keeping on blisters 

* In pulmonary diseases, this continued discharge- is often very useful, and 
should be encouraged ; but in fever the production of such an effect from blisters 
must be avoided, as a surface thus denuded of its cuticle and inflamed, may be 
converted into a dangerous sore. 



312 GRAVES^S CLINICAL LECTURES. 

for twelve, eighteen, and twenty-four hours, and for having shown, 
by numerous experiments, that a much shorter period of time was 
required to insure the full effect of these remedies. When I com- 
menced the practice of medicine, blistering was looked upon bv 
most sick persons as one of the severest trials of their patience, and 
the agony which it caused in some irritable habits was almost in- 
supportable. Blisters were left on for twelve, eighteen, and even 
twenty-four hours, and when at length they were removed, the 
whole epidermis of the blistered part came, or was torn away, 
leaving behind a raw irritable surface, from which large quantities 
of serum and pus were eft'used for several days, to the great torture 
and inconvenience of the patient ; and, not content with this, the 
practitioners of that time generally dressed the excoriated surface 
with some sharp stimulant ointment, so that the blistered surface 
most commonly resembled that of a severe burn. Ask those who 
are our seniors in practice, and they will tell you what blistering 
was twenty or thirty years ago. They first produced excessive 
irritation of the skin, by leaving the blisters on too long, they then 
irritated the denuded surface with stimulant ointments, and in this 
way broucrht on extensive sores of a bad character, Vvhich remained 
long after the disease for which the blisters were applied had dis- 
appeared, and which formed, in fact, a new ailment, requiring new 
medicines and additional attendance. If you look over Mr. INloore's 
account of the principal remedies employed in the practice of Dub- 
lin physicians, about the period I allude to, you will find that no- 
thing was more common then than the application of stimulant and, 
as they were termed, digestive ointments, to blistered surfaces. I 
was among the first who assailed this barbarous treatment, and 
showed that all the good effects of blisters might be secured by 
leaving them on for a much shorter space of time. I proved by 
numerous experiments, that in many cases it w^as not necessary to 
leave them on more than four or five hours, in the adult,* and that 
they might then be removed and the blistered part dressed with 
spermaceti ointment. Under this dressing the blister rises well, 
and there is no danger of tearing away the cuticle, or producing an 
irritable sore. In addition to this, you entirely avoid the irritating 
effects which blisters are known to produce on the urinary organs. 
You will very rarely meet with dysuria, or haematuria, where the 
blister has been left on for the spaces of time I have mentioned. 

Blistering is, then, to be used with the restrictions I have men- 
tioned, and you will find it a most valuable aid in the treatment of 
fever and its complications. It may be employed either as a deri- 
vative and revulsive, or you may have recourse to flying blisters 
over various parts of the body, in certain forms of fever, where 
there is marked and sudden depression of the powers of Hfe. 

* Of course blisters applied to the scalp BQUst be excepted. They require at 
least twelve hours. In old persons generally the skin is much less vascular tkan 
during youih or middle age; and consequently, in the old, blisters require a 
much longer time to produce the required effect. 



GLANDERS. 313 

Speaking of depression of the powers of life reminds me of a cu- 
rious incident, which occurred some time since in my practice, and 
which shows the value of being acquainted with the peculiar habits 
and idiosyncrasies of famihes. I attended, with Mr. Kirby, about 
three years since, a gentleman of middle age and active professional 
habits, who had been attacked with fever. I was first called to see 
him on the ninth day of fever, and found him apparently moribund. 
His pulse was intermittent and irregular, the action of the heart 
tumultuous, the respiration feeble, and the extremities cool. Mr. 
Kirby had instantly ordered internal stimulants, and blisters over 
the region of the heart and epigastrium. The patient rallied, and 
ultimately recovered. It is to be observed, that the group of formi- 
dable symptoms just enumerated had supervened quite out of the 
usual course, and without any previous warning. They were con- 
sequently not only alarming but unexpected. About a month after- 
wards Mr. Smyly and I were called to see this gentleman's brother, 
who was living at Dundrum, and who was supposed to have caught 
fever from his close attention to his brother during his illness and 
convalescence. What was most remarkable in the case, w^as, that 
his pulse began to flag and intermit, and he likewise suddenly and 
unexpectedly got the same symptoms of depression of the vital 
powers on the very same day and hour as his brother. His symp- 
toms also continued for the same length of time, and yielded, or 
spontaneously ceased, under the same plan of treatment. In some 
families you will find a very curious coincidence between the play 
of the various functions in diseases as well as in health, and you 
should neglect no opportunity of making yourself acquainted with 
the family peculiarities and idiosyncrasies of your patients, as know- 
ledge of this description is of the greatest value and importance in 
the treatment of disease. 



LECTURE VIII. 

Glanders and button-farcy in the human subject — Particulars of a case of glanders, 
with the post-mortem appearances — Remarks on the variety of skin diseases produced 
by the introduction of an animal poison into the system — Case of button-farcy — 
Analogous appearances, where, as in typhus, an animal poison is sometimes gene- 
rated in the body — Furuncular inflammation, or carbuncle, generated by animal 
poison ; also tubercles — Sometimes a preternatural whiteness precedes the purple 
hue of mortification — Remarks on phlegmasia dolens — Phlegmasia dolens of the 
eye. 

In pursuance of my intention, as announced in a former lecture, 
I shall proceed to-day to the consideration of two affections result- 
ing from animal poison, one of which has been but recently intro- 
duced to the notice of the medical profession ; of the other, I am 
not aware that there are any published cases in existence, I allude 
here to glanders and button-farcy in the human subject, 

27 



314 GRAVES'S CLIAICAL LECTURES. 

The profession is chiefly indebted to the researches of Dr. Elliot- 
son for the first accurate account of glanders in the hunaan subject 
— a disease which has now excited a very large share of attention 
here and on the continent. Many other observations, published 
since Dr. Elliotson undertook the illustration of this disease, have 
established the fact, that the morbid matter secreted by horses 
labouring under glanders may communicate the infection to the 
human subject, and thus give rise to a loathsome, painful, and 
generally fatal disease. From the notices which I have been able 
to collect, it appears that glanders in man is of very frequent occur- 
rence in Ireland — so frequent, indeed, that I think the legislature is 
called on to imitate the wise example of the Prussian government 
in placing glandered horses under the surveillance of the police. 

Like many other animal poisons, that of glanders does not seem 
capable of affecting every individual indiscriminately; indeed, the 
average susceptibility must be small, for grooms and veterinary 
surgeons take few or no precautions in examining the diseased ani- 
mals ; and yet the proportion infected, compared with the number 
exposed, is by no means considerable. That such persons exhibit 
great carelessness in examining glandered horses, appears from the 
directions given' in books on farrier\', *• that the finger should be 
introduced into the nostrils for the purpose of ascertaining whether 
certain spots suspected to be ulcers are so or not." JSow, when the 
viscid gluey nature of the discharge from the nostril is taken into 
account, we cannot but conclude that this operation of introducing 
the finger into such a mass of vitiated and poisonous secretion 
w^ould more frequently prove the means of infection, were the 
human constitution verj^ susceptible of the poison — ^for we are to 
recollect that the fingers of such persons are seldom free from 
scratches and abrasions. 

I shall now read the following case of glanders in the human 
subject. It is one of extreme interest, and has been most faithfully 
and graphically detailed. It occurred in the Richmond Hospital, 
and has been communicated to me by Dr. M'Donnell. You will 
find in it many points of reseniblance to a series of cases translated 
from a German journal, and published in a late number of the 
Medico-Chirurgical Review. 

Patrick Wallace, a healthy muscular man, aged twent}^ was 
admitted into the Richmond Surgical Hospital on the 6th October, 
1836. It was stated that he had been in care of a glandered horse 
— driving, cleaning, (fcc- — and that he had been in the habit of 
drinking out of the vessel from which the horse drank. It ap- 
peared, also, that he had had an abrasion on one of his ears. On 
admission, he had much of the appearance of a person labouring 
under cynanche tonsillaris: he could only open his mouth to the 
extent of half an inch ; this was the only uneasiness complained 
of. The left tonsil was very much enlarged, red, hard, and pro- 
jecting towards the middle line ; no fluctuation could be felt ; there 
was a general fulness about the angle of the jaw, extending upwards 



GLANDERS. 315 

nearly as far as the zygoma. The sub-maxillary gland on the same 
side was also enlarged and indurated. These symptoms had been 
ushered in by feverishness, a few days previous to admission. He 
was ordered to have eight leeches to the throat, to be followed by a 
poultice, and a bolus composed of calomel and jalap. 

Next day the external swelling was found to be increased ; greater 
difficulty of opening the mouth ; the tonsil still hard and swollen. 
Twelve leeches were applied to the fauces, and the patient took the 
tartar emetic mixture of the hospital, with sulphate of magnesia. 

On the 15th of October, the disease is reported to be on the 
increase. Tonsil still hard, but no fluctuation ; left side of the 
face greatly swollen; eye of same side nearly closed, from tume- 
faction of the lids; general inflammatory appearance over the 
cheeks, and great hardness of the tissues about the angle of the jaw 
of the same side, extending towards the chin ; several circumscribed 
spots of redness, varying in extent from the size of a sixpence to 
that of a halfpenny, with irregular margins, scattered over different 
parts of the body; two pustules observable on the left leg. 

16th. — A vesicle containing a yellowish serum observable on the 
left tonsil ; the same inability of opening the mouth continues ;• 
increase of swelling over the left side of the face ; a small abscess 
has formed on the posterior part of the left fore-arm ; some delirium 
during the night: three evacuations from the bowels. The tonsil 
to be brushed over with a solution of nitrate of silver ; a blister tO' 
the fauces; the tartar emetic mixture to be continued. 

17th. — Some sleep during the night, interrupted by delirium of a 
low muttering character. Patient appears willing to answer ques- 
tions, but cannot, from obstruction in the mouth. This, however, 
lasts but for a moment, and he then lapses into a state of inco- 
herency. Mouth open to the extent of half an inch ; left eye closed ; 
considerable swelling of the left side of the face, which is indurated, 
hot, tense, and shining; all the glands on both sides of the jaw, but 
particularly on the left, are swollen and hard ; same state of tonsil ; 
nares dilated ; breathing stertorous, somewhat hurried, about 28 in 
the minute, and interrupted by frequent sighs. Pulse very small, 
rapid, intermitted, and cannot be counted; skin hot, tongue furred, 
teeth covered with sordes. He complains of great thirst, but says 
he feels no pain ; it is evident, however, that he feels great uneasi- 
ness in the joints and limbs when moved. There is, however, no 
swelling or redness of the joints ; there is no discharge from the 
nostrils, nor is there any perceptible ulceration of the mucous mem- 
brane of the nose. No apparent afl^ection of ihe absorbent glands 
in any other part of the body. 

During this period, vesicles and pustules of various sizes, and at 
various stages of growth, had made their appearance on difl!erent 
parts of the body, particularly on the back. They varied in size, 
from the head of a pin to the section of an almond. In the first 
stage, they resembled very minute vesicles, scarcely surrounded by 
any inflammatory border, and containing a limpid serum. In the 



S16 CcSATlS^ C&ifiiOM. U. 



slage, Ibe seriHD wsas ae- : t i -tub a gud- 

sidbjBible biosb of rsdoe^ aimsiifid i_. .. i :.. ^ :.__ :.: ihis iDsi^id 

fcecame gxsatlj inrTBasBJ in siza. When one of ibe Tesicles ^wa$ 
fimcttired, the ssnam afipeaasd io ©amg irasQ a sicr ? 77- — i-^rer 
^e cntide: this <£|)esrad[iBn i&i. msA fradnae anr e: ir 

itmaoizr, a ccm^dsi^bfe imrdness sl31 leaisi: : : :iii£ or 

it, wilii a cawaty ih the cfinupe ib i» : . z^ -vts 

^aied to^£Sber, anii maL niDefa larger liaffl iteiit: _ _: ^ : . esr 

ciflsierB were SQiroDnded dt whMB rwssA maatrgiraB, i^i : . :r 
llie appeai^nee of vheais, sjid about aiBBeaBDC ^ -^r eF 

in iff^dtbt bei^'een tbsse thw^bs and aifae sittr i 7:11. 

line of isdn^s. Tiie wbole laten lo^eiaBr s.^ l^ 

sbape. Tiiere siso esisied BflmerooE iifis-r: lir 

rigb: sboaidea-a 3sit ardB&, ani todibsr |»i^ c : t i -e 

of a dark biieiimi appnsac&ii^ 1» £ £wai : : ~~ : . t t if 

mads on ibeis ibe eoimir (fe^fiB«n^ tet itEHanseinnDsdiamiT iniiesi 
it is remoTsd- Oa rmmanv ife 3633^0* «wBr i^sin ? ^~r ^^^d 
AoBOiir was feJt in tbe centre; ibe nmn^mm ^f 1: t r t 

irragnlar. 

On tbe 17ib, ibe cbaracler of tbe djssafie il^caBe anaie flbdnlw' 
developed: ai ibree o'-cloek. ium, pas i 
obsBTFed Id issoe from both soslzife. Tte 
take tbe solution of chlorate od'saaia ittfBiiBii ^ 
ttmes m day ; and also a mixtm^ esrapoasd tslf csuibona^ cf SHBrao- 
^2L, £^p»r siberis oleosLs, and eanfbor suxiHne. J^ S <D'^ck>c^ 
F.m^^ was found half out of bed, ifa^ ^ad i^sliBg «ib t&fae pffisFW ; 
wMe to express his wants : psike not io le cxoa^ei ^ l^s send 

sonace of tbe Sodr. Tbe pnivte^ &sEkBa^ §x&m tdis mgw^fcrik 
bnt tbere is a disr.bar^ of macns from tbe montiL. wilb 




fetor of bi^atb. 

S o'clock, P.M. — ^A copioQS ^rspiratjon i^ breiEB iSBii; -iwsr tte 
body; face red. ISDBe, shining, and Terr mncfa swelled ; su^lin^ 
ims J10W extended to the jip:bl side of trie face ; right ex^ Tjearjv 
^en the left better; afewpnstaiffi iiav^ 7 jeir 

ii tbe kmer ^antbns of tbe eye. Poise, : : r Lnd 
skin, as in ^^gt nignait ; dbs&i 

Died at 4 ^"do^, ^ m^ Ckstater IMl 
On examining tbe body ^ hsoBse, afier death, tbe refines was 
foDnd to have disappeared from aiiB &u3e; the glands ai^pjit the ^eit 
angle of tbe lower jaw as IrfaiE imBrtfiwned : they w^a^ fiaiiidl 
Hial&d to tbe snrronndiug parts. Tie cfflBflkir ^asne (cawraaring the 
fldboB^xiiiaTT and parotid glan^ was inShaateJ 'wiA. seatnm. and 

<af Ae>£ibnEBs3l]afT w3eA foora^d^bafe. 7%e InsaHB was finn, boi 
its I'caatricles contained m cwiHwdarafcte '^lOHditg^ «ff &■!;; Ae aaacib- 
SGDii iBeii^>rane was ^cfn^psm raaa^ filac^; leessaai fadcbesifif 
were obsBned ob 9iks fia onater. The ikmigs y wiiiiiiit 



BUTTON-FARCY. 3X7 

a congested appearance; numerous pustules were scattered over 
their surface — some separate, yellow in the centre, and surrounded 
by an ecchymosed border ; others existing in clusters. They resem- 
bled, in every respect, those found on the surface of the body. The 
lining membrane of the larynx was very much inflamed, especially 
about its upper part and about the epiglottis. The inflamed parts 
in this situation were of a livid hue. There was some appearance 
of vesicles in the trachea, but this could not be satisfactorily ascer- 
tained. The bronchial tubes were filled with mucus. The stomach 
contained a quantity o-f yellowish-green mucus ; its lining mem- 
brane presented an ecchymosed and inflamed appearance. The 
liver was somewhat enlarged, and adhered by its inferior margin 
to a few folds of intestine. The periosteum did not exhibit any 
appreciable deviation from the normal state. 

One of the chief things to be noticed in the foregoing case is the 
variety of inflammatory affections observed in the skin as the result 
of the introduction of an animal poison into the system. There 
was, in the first place, the general diflTused redness of the face, then 
superficial inflammatory spots on the shoulders and arms, resem- 
bling erythema nodosum ; in the next place, scattered pustules of 
various sizes, comm.encing in the form of a vesicle, which after- 
wards became a pustule surrounded by an inflammatory zone ; and 
lastly, achores congregated together and surrounded by an elevated 
white margin, within which there existed an inflammatory ring of 
a red colour. Another point worthy of notice is the state of the 
lungs and bronchial mucous membrane. The lining membrane 
of the larynx, particularly in the vicinity of the epiglottis, was 
inflamed and of a livid colour, and there was an indistinct appear- 
ance of vesicles in the trachea. But what was particularly deserv- 
ing of note in the lungs, was the existence of pustules on their 
surface, bearing the closest resemblance to those found on the 
surface of the body. It is not stated whether there wa« any appear- 
ance of of vesicles or pustules in the nose-, pharynx, or cesophag-us, 
but we are told that the stomach- was ecchymosed and inflamed. 

The following case was witnessed by myself and Dr. Halahan, 
and seems more nearly allied to the variety of glanders termed 
button-farcy. I regret that want of time has prevented me from 
arranging its details in a form more worthy of your attention; and 
were not the disease one of comparatively rare occurrence, I should 
not have ventured to lay the case before you inits present imperfect 
state. 

The subject of this case was a gentleman residing at Rathmines, 
an extensive proprietor of horses, and who, having originally gra- 
duated as a surgeon, exhibited much skill in the veterinary art. 
About the time of his illness he had had some horses in^ his esta- 
blishment labouring under glanders and button-farcy,, to which he 
paid particular attention. After having' laboured' for some days 
under considerable lassitude and derangement of the stomach and 
bowels, he was attacked^ on the 8th of Julv, with- rigors, followetl 

2-7* 



318 GRAVES'S CLINICAL LECTURES. 

by great thirst, excessive heat of skin, and pains in his limbs. The 
moment he felt himself attacked in this way, he said he was sure 
that he had got some dangerous infection from the horses, and 
would never recover. He took some blue pill and colocynth, which 
produced a few dark and very fetid evacuations. On the 9th, his 
pulse was 94, his urine very high coloured, his thirst and feverish 
symptoms rather increased, and he suffered greatly from constant 
nausea and vomiting. A tumour now began to appear about three 
inches above the inner ankle of the right foot. He applied a poul- 
tice over it, but was obliged to remove it in a short time, in conse- 
quence of the pain occasioned by its weight. The tumour was 
about the size of half a walnut, of a dull red colour, tense, shining, 
and exquisitely painful. Its external aspect was peculiar, and 
might be compared to something intermediate between a boil and a 
spot of erythema nodosum. On the 10th, another tumour of the 
same character appeared near the outer ankle of the same leg; and 
in this way the disease went on, tumour after tumour appearing on 
different parts of the body, with an increase of the feverish symp- 
toms, until the :20th of July, when he was first seen by Dr. Hala- 
han. At this time several tumours had appeared on different parts 
of his body ; there was one of an extremely painful character on 
his head, and he complained of great tenderness and pain along the 
right clavicle. His thirst was still urgent, his restlessness excessive, 
the slightest motion gave him exquisite pain, and sleep had com- 
pletely abandoned him. He had endeavoured to regulate his 
bowels by purgative medicines, and had applied leeches to the 
tumours and to the clavicle at various times, but w^ithout any de- 
cided benefit. There were eight or nine tumours on different parts 
of the body, of the character before mentioned, without any ten- 
dency to suppuration, and so exquisitely painful that he could only 
bear a single sheet over him. The inflammation about the clavicle, 
which was of a diffuse character, had extended up the neck and 
over the right shoulder; there was not much swelling, except about 
the clavicle ; the colour of the affected parts was a peculiar dusky 
red. Immediately over the clavicle two vesicles were observable, 
filled with a transparent fluid. Three dozen leeches were ordered 
to be applied over the clavicle and shoulder, and the patient was 
directed to use chickenTbroth, beef-tea, and other light nutritious 
articles. 

On the 21st, all symptoms are stated to be on the increase. His 
fever, thirst, and sleeplessness, are undiminished ; his tongue furred 
and dry; his teeth covered with sordes ; his pulse small, weak, and 
rapid; his nausea and vomiting not so troublesome. He had re- 
ceived no benefit from the application of the leeches ; the swelling 
and stiffness of his neck was increased, and he had now some 
difficulty of swallowing. The erysipelatous surface of the neck, 
clavicle, and shoulder, were lightly brushed over with lunar caustic, 
which gave the patient an agreeable sensation, and from which he 
stated that he derived much relief. This was repeated the next 



SYMPTOMS OF GLANDERS. 319 

day at his own request, and with equal benefit; the difficulty of 
deglutition diminished, and for two days he went on pretty well. 
On the 25th, there was an evident increase of fever ; the tumours 
over the body and limbs were increasing in size and number; and 
his anxiety, restlessness, and sufferings unabated. He had taken 
alterative doses of calomel and James's powder, and his bowels had 
been regulated by mild aperients and enemata. I saw him for the 
first time on the 28th. His pulse was then 98, small, and easily 
compressed; his thirst excessive; his restlessness and agony such 
as would strongly excite the pity of persons most conversant with 
scenes of human suflfering. He had several tumours over different 
parts of his body, all exquisitely painful, and in their aspect some- 
thing between boil and erythema nodosum. Some of them were 
hard to the touch ; others, which appeared more advanced, were 
softer, and had a boggy feel. There was, however, no appearance 
of anything like suppuration. He was ordered sulphate of quinine, 
chicken-broth, ale, and other light nourishment, and an opiate at 
night. On the 31st, a tumour appeared on the right side of his 
forehead, larger and more painful than any of the rest. Another 
of a similar character showed itself on the right clavicle, which 
had been previously affected. Shortly after their appearance, 
vesicles w^ere observable on their surfaces, such as generally pre- 
cede mortification in cases of anthrax and malignant carbuncle. 
Next day he was evidently worse ; his pulse was 108; his fever, 
pain, and restlessness, unabated; and a miliary eruption began to 
make its appearance over his chest and abdomen. The vesicles 
now began to increase on the surface of the tumour ; his fever and 
restlessness w-ere aggravated ; and his m.ind, which had been 
hitherto collected, began to wander. His restlessness was so exces- 
sive, that he could not remain for a moment in the same position ; 
and being a person of much mechanical ingenuity, he had a set of 
pullies constructed and fastened to his bedstead, so that he could 
move himself in various directions. His medicines and diet, with 
the addition of claret, and opiates at night, were continued as 
before. 

On the 6th of August he was still w^orse; the tumour on the 
head continued to enlarge, and decided sloughing had taken place. 
The tumour on the clavicle presented the same aggravation in 
appearance and character, and a fresli tumour had appeared on the 
back of his head. A pustular eruption now began to make its 
appearance over his body, chiefly over the abdomen and limbs; 
his symptoms became aggravated in every respect; the delirium 
and watchfulness increased; and he died on the 10th of August, 
about thirty-three days from the commencement of the disease. He 
attributed his illness to attending horses, four of which had died of 
button-farcy; and what is also curious, his nephew, who had also 
been engaged about the diseased animals, had fever of a typhoid 
character, with petechise of a larger sort than usual, but ultimately 
recovered. 

The symptoms of glanders in the human subject have been so 



320 GRAVES'S CLINICAL LECTURES. 

fully detailed by Dr. ElHotson and others, that it only remains for 
rae to make a few observations connected with this subject. In the 
first place, it may be observed that most diseases produced by the 
deleterious effect of animal poisons on the economy, show a ten- 
dency to cause not only fever, often of a malignant character, but 
also various forms of external disease, chiefly limited to the super- 
ficial gland, subcutaneous celluhir tissue, and skin. In urticaria, 
small-pox, and measles, the external disease is chiefly limited to 
the skin; in scarlatina, we have often swelling of the parotid gland, 
with inflitralion of the adjacent cellular tissue in addition to the 
cutaneous eruption ; in syphilis, and cases of dissecting wounds, 
we have disease of the skm frequently combined with an affection 
of the superficial lymphatic glands. The same observation applies 
to typhus, many easels of which are characterised by an eruption 
of spots over different parts of the body, or by the occurrence of 
what are termed petechi^e. On these matters I need not enlarge, 
as you are aB well acquainted with them ; but that vesicles and 
pustufes very similar to those observed in dissection wounds, and 
other diseases produced by the direct introduction of animal poison 
into the system, may arise from the action of morbid changes spon- 
taneously occurring in the body, is a fact which admits of being 
proved, and op'cns to us a new and interesting field of inquiry. 
Thus, in eases of typhus, where the effect of pressure or some 
other accident has occasioned bed-sores of a bad character, and 
even where there are no bed-sores present, I havx on several occa- 
sions seen low secondary fever produced, and have observed vesi- 
cles or pustules appear on the skin, simihr to those described by 
Mr. Colles as accompanying the fever of dissection wounds. An 
example of this occurred some time ago at this hospital, and you 
have recently w-itnessed another in the case of a young man reco- 
vering from typhus. It might be argued that the secondary fever 
and eruption in such cases arise from the absorption of morbid 
matter into the system, and I am willing; to admit that there is some 
colour of argument for this statement, where the patient labours 
under bed-sores of a bad and gangrenous character; but that this 
explanatio-n is not the true one appears from the case of the young 
man to which I have alluded. He had no bed-sores to account for 
the secondary fever and eruption; and we can only explain by 
supposing that H is the result of a poison generated in the system 
during the course of fever. This is particularly deserring of 
Dotice, as I am not aware that any author on typhus has noticed 
this symptom, or pointed oiK the circumstances under w^hich it 
occurs. The same pheno-menon is occasionally observed, where, in 
consequence of external injury, diffuse cellular inflammation has 
taken place. Thus, several years ago, a woman was admitted into 
the Meath Hospital, who had diffused cellular inflammation in con- 
sequence of receiving a kick on the chest. After a few days, 
Colles's pustules appeared on different parts of the body, and she 
died with symptoms of croup. On dissection the crouny symp- 
toms were found to depend on an eruption of vesicles filJed with 



I 



REMARKS ON ANIMAL POISON. 321 

opaque serum, over the lining mennbrane of the larynx and trachea. 
Something analogous to this was observed in the case of Wallace; 
and the coincidence is further strengthened by the frequent occur- 
rence of disease of the lining nnembrane of the larynx and trachea 
in many other febrile affections accompanied by cutaneous erup- 
tion — as small-pox, measles, syphilis, and scarlatina. 

Another point which is deserving attention with reference to the 
phenomena of external disease, in cases where animal poisons have 
been generated in the system or arisen from infection, is the occur- 
rence of tumours in different parts of the body, partaking of the 
characters of furuncular inflammation or carbuncle, and running 
through a somewhat similar course. These tumours formed a very 
prominent feature in the case of Wallace ; and in the gentleman 
who laboured under button-farcy, they constituted one of the most 
important symptoms of the disease. We also observe something 
similar to this in that form of venereal which Mr. Carmichael terms 
tubercular, and which is characterised by the appearance of small, 
hard, dark red tumours, on various parts of the body, which exhibit 
a very imperfect tendency to suppuration, and frequently give rise 
to sores of a bad and unfavourable character. Another circum- 
stance observed in Dr. M'Donnell's case deserves some share of 
attention; I allude to the white elevated margins, like wheals, 
around the redness which more immediately encircled each cluster 
of achores, and which we are to look upon in a less advanced 
stage of its progress, being as it were only the first stage of the 
latter. It is a curious fact, that on many occasions a preternatural 
degree of whiteness precedes the redness and congestive purple hue 
"which ushers in mortification. This is generally known in the 
■case of the nose when frost-bitten, and which always appears pre- 
ternaturally white in the commencement. Something analogous to 
this was observed in some cases of bad typhus treated here in 1826 
and 1827. The nose sometimes assumed a peculiar white colour, 
and not unfrequently exhibited a tendency to mortification. When 
first seen it had a preternatural whiteness, and looked very like a 
nose made of white wax ; in the course of a few hours it changed 
to a purplish red, and exhibited symptoms of approaching gangrene. 
Again, in urticaria, we often see some portions of the inflamed skin 
assum.e a white colour, and the same occurrence may be noticed 
likewise in the wheals caused by nettles or the stings of bees. In 
general, we connect the idea of integumental inflammation with 
the appearance of redness ; and this phenomenon is explained on 
the hypothesis that a preternatural quantity of blood is circulating 
in the inflamed parts. How, then, are we to account for the facts I 
have mentioned ] To what cause are we to attribute the co-exist- 
enc^f increased vascularity, and a remarkable whiteness or pallor 
of the parts'? — a state displayed in a very remarkable manner in 
phlegmasia dolens. 1 think the explanation is not very difficult, 
when we recollect that the capillary vessels of the white tissues of 
the body contain no red blood in their healthy state. It is easy to 
conceive that in certain stages of inflammation the quantity of 



322 GRAVES'S CLLMCAL LECTURES. 

serous or white blood circulating in any of these tissues may be 
suddenly much increased, and that this increase ma}^ be accompa- 
nied by all the phenomena of inflammation except redness. In 
certain cases, as phlegmasia dolens, the colour is permanently 
white: in other cases the while is exchanged for redness, when 
the inflammation has increased in intensity: but perhaps we should 
not use this expression, for the phenomena of phlegmasia dolens 
prove that a white inflammation may be quite as intense as red 
inflammation, — a fact which I saw exhibited in a remarkable 
manner in the case of a woman in this hospital, labouring under 
phlegmasia dolens, and in whom the disease suddenly attacked the 
e^'e, and destroyed it in a short space of time — disorganising it 
rapidly without the supervention of any redness during this de- 
structive process. Phlescmnsia dolens of the eye constitutes a 
disease never before remarked in that organ, and its occurrence 
and phenomena were peculiarly valuable in expiainiDg the true 
nature of that remarkable disease. Having already published an 
account of this case, I shall not at present enter into further details, 
but merely state that the woman affected laboured under well- 
marked phlegmasia dolens of the leg, occurring after delivery, and 
that the disease of the eye came on very suddenly, and was accom- 
panied by agonising pain and exquisite tenderness in the conjunc- 
tiva covering the sclerotic. This membrane was in a very few 
hours tumefied, and distended in its subjacent cellular tissue by a 
perfectly colourless effusion of fluid, apparently sero-gelatinous, and 
which raised up the membrane itself so as almost to conceal the 
cornea from view. In the course of the day the internal structures 
of the eye became engaged, and vision was speedily destroyed. 
This case appears conclusive against the doctrine that phlegmasia 
dolens depends on inflammation of the veins. I am sorry that Mr. 
Middlemore has failed to notice phlegmasia dolens of the eye in 
his late admirable work on the diseases of that organ. 



LECTURE IX. 

On the Bse of emetics at the commencement of fever; not so wdl adapted to a later 
period — Domestic remedies for feverish colds ; these colds prove to be fevers, and 
time is lost — Protest against the pbuse of purgative metlicine in fever — The idea 
of curing fever by purging is absurd — Treatment where the bowels have become 
almost paralysed from the cure of preceding diarrhoea — Venesection as a means of 
checking fever — Beneficial even within the first twelve hours after seizure bj typhus 
— Various cautions respecting leeching and cupping-glasses — Mode of ap p lying 
leeches when pneumonia or hepatitis supervenes on fever. -^L^ 

I HAVE already observed that it is not my intention to ^ive a 
regular sketch of the practice to be adopted in the treatment of 
typhus. I have designedly passed over many important points, 
being unwilling to trouble you with any observations on practical 
matters in which my opinions coincide with the latest and best 



TREATMENT OF FEVER. 323 

authorities. I shall therefore touch very briefly on the subject of 
emetics in fever, as the rules by u'hich the administration of these 
remedies are regulated have been laid down with precision by 
many modern writers. I am not in the habit of using emetics in 
fever, except when called in at the very commencement of the dis- 
ease. Here emetics are of great value, and will often succeed in 
stopping the fever. There is no way in which you would be more 
likely to cut short an attack of fever than by the administration of 
an emetic, if you chance to see the patient when the fever is just 
beginning. I speak here without any subterfuge, and without 
grounding my opinions on the results of doubtful or merely sus- 
picious cases. I speak not of cases of bad feverish cold, in which 
the symptoms, at the commencement, bear a very strong analogy 
to those which usher in typhus; I speak of cases where the patient 
gets rigors, followed by the usual symptoms of feverish excitement, 
after exposure to contagion, and is seen on the evening of seizure. 
If I were called to visit a patient who had been attacked with 
shivering, headache, quickness of pulse, increased temperature of 
skin, and lassitude, during the prevalence of an epidemic, or after 
exposure to contagion, and happened to see him a few hours after 
the attack, I should cetrainly bleed him, and administer an emetic; 
and I think he would have a very good chance of escaping the dis- 
ease. I think the exhibition of emetics an excellent practice in the 
commencement of fever, but 1 must observe, that the period of 
their exhibition is very brief. After the lapse of twenty-four or 
thirty-six hours from the occurrence of the rigor, they will not suc- 
ceed in cutting short the fever. A few hours make a vast differ- 
ence in the chances, aqd after the lapse of twenty-four hours, there 
is, generally speaking, very little hope of extinguishing the disease. 
At the termination of this period, it has in most cases seized hold 
of the constitution too firmly to be shaken off by an emetic, even 
though aided by bleeding. But for the first few hours after 
seizure, the plan I have mentioned affords you a reasonable hope 
of being able to put a stop to the mischief at once. Army surgeons, 
and practitioners who have opportunities of treating incipient dis- 
ease, are well aware of the truth of these observations. I hav© 
myself witnessed many cases, in private practice, of medical men 
and students, who had been attacked with symptoms of fever after 
exposure to contagion, and who escaped by taking an emetic, and 
being bled in proper time.* 

Except at the commencement, I am not an advocate for the use 
of emetics in fever. They fail in checking the disease, and they 
are apt to be followed by considerable debility of the stomach and 
general system — "states which it would be better to avoid, where 
the patient has to run through the course of a long and exhausting 

* [In the epidemic at the Philadelphia Hospital in the year 1836 it was found 
that emetics were of great benefit, and diminished the violence of the fever ; their 
power in cuUing short the disease when it had fairly taken hold was not so well 
ascertained. One of the best emetics is the infusion of eupatorium. — Ed.] 



324 GRAVES'S CLINICAL LECTURES. 

disease. If called to a case of fever in which you cannot give an 
emetic, there are two or three other remedial agents you may 
employ to moderate the feverish excitement, and render the disease 
milder and more manageable during its progress. One of these is 
James's powder, with which you may combine blue pill or hydrar- 
gyrum cum creta, if necessary, giving two or three grains of each 
every third or fourth hour, according to circumstances. Another 
remedy, which many are in the habit of using, particularly where 
the fever is accompanied with symptoms of inflammatory excite- 
ment, is a weak solution of tartar emetic. Two grains of tartar 
emetic may be dissolved in a pint of barley water, and of this mix- 
ture a table-spoonful may be taken every second hour. These are 
good and useful remedies in the first stages of fever ; they moderate 
the feverish excitement, act gently on the bowels, and produce more 
or less diaphoresis. 

It most commonly happens that the physician is not called to see 
a case of fever until forty-eight hours, or perhaps three or four days, 
have elapsed, from the period of seizure. In this climate, feverish 
colds are extremely frequent ; and as their symptoms bear consi- 
derable resemblance to those of incipient fever, and very few are 
capable of making a distinction between them for some time, a per- 
son attacked with fever usually regards it, at the first onset, as the 
result of cold, and expects to be able to alleviate or remove it in a 
few days by bathing his feet and taking a warm drink at night, 
with, perhaps, some opening medicine on the following morning. 
The usual period, however, at which the feverish cold had been 
accustomed to decline, passes over without the expected amend- 
ment, the patient feels himself weaker and worse, the conviction is 
brought home to him that his disease is something more than an 
ordinary cold, and he sends for a physician about the third or 
fourth day. Now at this period, I believe, you must be content to 
let the fever run its course ; for it has taken root too deep to be 
expelled by a coup de main, and yet many persons seem to think 
they can still succeed by what they term bold and decided treat- 
ment. The mode which they generally adopt is, first, to administer 
an emetic, and then to have recourse to copious and continued pur- 
gation. This leads me to say a few words on the use of purgatives i 
in fever. 

The abuse of purgatives, particularly in the first stage of fever,^ 
continues, I am sorry to state, even to the present day, a blot on' 
the character of practical medicine. Large doses of calomel, and 
vegetable purgatives, in the form of pill or bolus, and followed up 
by draughts composed of infusion of senna, Epsom salt, and elec- 
tuary of scammony, form the chief part of the treatment in fever 
with too many practitioners. I know well that this is a mode of 
proceeding too commonly employed, and I have frequently heard 
those who adopt it, when questioned as to the remedies they have 
used, declare, with much self-satisfaction, that the patient's bowels 
have been well cleared out. This, I believe, is a very common 



TREATMENT OF FEVER. 325 

mode of treating fever in the incipient stage ; and though there can 
be no objection to the administration of a purgative, as a cautionary 
measure, particularly where an accumulation of fsecal matter in the 
bowels is suspected, I must confess that my experience does not 
authorise me to sa}', that fever can be either checked or mitigated 
by continued purgation. If active purgation does not check fever 
in the commencement, what benefit, then, can be expected from it? 
People will tell you that full purging must act beneficially in two 
ways; by unloading the bowels, and by evacuating the general 
system. With regard to evacuating 'the bowels, I think it can be 
done well and sufficiently by the use of mild aperients. It is sel- 
dom necessary to give active purgatives, and we never have occa- 
sion to continue their employment from day to day. The bowels, 
I repeat, can be sufficiently unloaded by the exhibition of mild 
aperients and enemata, and even these will seldom be required 
more than once or twice in the commencement, and occasionally 
during the course of the disease. The second question (in refer- 
ence to the use of purgatives as general evacuants) is, whether it 
is prudent or safe to act antiphlogistically on the system through 
the medium of the intestinal canal, during the first stage of fever? 
My opinion is, that it is not. I grant that the administration of 
active purgatives is followed by a copious evacuation of the fluid 
secretions of the intestinal canal, and that in this way you deplete 
the system to a very considerable extent. Admitting all this, and, 
moreover, that depletion is required, still I am of opinion that this 
is not the best way of effecting it, and shall always give a prefer- 
ence to the action of other remedies. I prefer the action of James's 
poW'der, or tartar emetic, or nitrate of potash, or leeches, or, in fact, 
any remedy which will act with less risk of subsequent mischief. 
I have observed that the abuse of active purgatives in the com- 
mencement of fever — nay, even the exhibition of cathartics two or 
three times, in the beginning of fever, in persons with irritable 
bowels, is very apt to induce excitement of the gastro-intestinal 
mucous surface, giving rise to early and profuse diarrhoea, tympa- 
nites of a bad and unmanageable character, and not unfrequently 
to disease of the mucous coat of the digestive canal. Great tender- 
ness of the belly, meteorism, and exhausting diarrhoea, are the 
general consequences of early and continued purgation. In private 
practice I can generally tell, by examining the patient's belly, 
whether he has been actively purged in the commencement of the 
disease or not. I invite you to study the cases that come before 
you in hospital, with reference to this point; I ihink you will find, 
in most instances, that the patients who have escaped active purga- 
tion before admission, will get through the disease with little or no 
tympanites. The physician who merely employs mild aperients 
and enemata — who does not use active purgatives from day to day, 
as is too often done — will not have his plans of treatment embar- 
rassed by the occurrence of dangerous tympanites, or obstinate and 
debilitating diarrhoea ; nor will he have the melancholy prospect 

28 



326 GRAVES'S CLINICAL LECTURES. 

before him of having an inflammatory affection of the gastro-intes- 
tinal mucous membrane to treat, at a period when neither the con- 
dition nor the constitution of the patient will bear anything like 
antiphlogistic measures. As to purging in general, the idea of 
curing fever by it is quite absurd. In fever, all the secretions are 
affected, and it would be idle to think of altering and improving all 
by acting on the bowels. Take the skin, for example. Consider 
what a departure there is from the normal state ; observe the quan- 
tities of moisture which exude from it without any apparent cause, 
or its equally inexplicable dryness. Its odour, its feel, its nervous 
and vascular conditions, are all more or less altered. Take the 
lungs, in the next place. There is generally some change in the 
smell of the patient's breath ; there is some change also in the quan- 
tity of the pulmonary exhalation ; there is an alteration in the rate 
and mode of respiration ; and I have ascertained, by experiment, 
that a person in fever does not consume as much oxygen, or give 
out as much carbon, as he would in a state of health. Observe 
the functions of the brain, or those of the hver or kidneys, and see 
how much they have departed from the normal state. Every 
secretion, every function, is more or less deranged, and w411 remain 
so as long as the fever lasts. You have no right to think that you 
will be able to restore the healthy state of the stomach and bowels 
any more than that of any other organ. The secretions of the 
lungs, liver, pancreas, kidneys, stomach, and skin, are all deranged, 
or more or less suppressed, and will not be restored to a healthy 
state until a crisis comes on, or the disease begins to decline. As 
long as the belly is soft and fallen, and where the bowels have been 
sufficiently opened in the commencement of the disease, I do not 
feel the least anxiety if the patient remains without having a stool 
for two or three days. I have, on some occasions in private prac- 
tice, been induced to consent to the exhibition of a purgative where 
J did not think it required ; and have seldom done so without 
regretting it afterwards. The patient has been going on well, the 
belly soft and fallen, no tenderness present, and no distinct evidence 
of faecal accumulation. All this I have pointed out to the practi- 
tioners in attendance with me, but to no purpose. They w^ould 
generally observe, in reply, " Oh ! this may be all true; but you 
see the patient has had no stool for the last thirty-six hours, and it 
would be quite wrong to let him go on in this way any longer." 
Indeed, you will frequently meet with cases in which you should 
exercise much caution in the administration even of enemata. An 
illustration of this remark occurred to Surgeon Ferrall and me 
lately in practice. In a case of fever in which the patient's friends 
were importunate as to the necessity of opening the bowels, the 
ordinary purgative injection was prescribed. It proved too active, 
and produced much irritation of the bowels, giving rise to an 
increased secretion of gas into the intestines, and a considerable 
degree of temporary tympanites. 

You will be guided, therefore, in the administration of purgatives, 



TREATMENT OF FEVER. 327 

not by the rule of those who are not satisfied with less than two or 
three motions in the day, but by the circumstances and exigencies 
of the case ; and you will be cautious in giving purgatives, except 
where you have good reasons to conclude that there is an accumu- 
lation of faeces. In this way you will avoid tympanites, diarrhoea, 
and inflammatory affections of the bowels ; symptoms which always 
give great annoyance to a practitioner, and tend greatly to embarrass 
his practice in the treatment of all fevers of a typhoid character.* 

So far concerning the administration of purgative as a cure for 
fever, or as a means of diminishing its violence. You perceive that 
I think their employment more than questionable, and in this par- 
ticular am consequently at issue with Hamilton, and a great number 
of writers. There are, however, circumstances which may arise 
during the course of typhus, and may require a free use of purga- 
tive medicines; we are then forced to have recourse to purgatives, 
not in the hope of curing the fever itself, but for the purpose of 
removing or alleviating certain superadded symptoms. It may be 
well to mention some of the chief of these symptoms. One of the 
most common is determination of blood to the head, producing 
delirium, headache, &c., &c. In many examples of this nature, 
occurring at an early period of typhus, purgatives of a very active 
nature are amongst our most efficacious remedies. Nay, even in 
the advanced stages of fever, delirium and determination to the 
head are seldom relieved by tartar emetic, unless it produces Very 
copious, yellow, watery stools. Many patients become uneasy and 
restless at night, in the latter periods of fever, in consequence of 
insufficient evacuations from the bowels; whenever, therefore, 
restlessness or sleeplessness supervene unexpectedly, and that the 
bowels are confined, the occurrence of these symptoms call for 
aperients, even though the belly be not very full and tumid. Pre- 
ternatural fulness of the belly, and tympanites, often demand pur- 
gatives at every period of the disease. In some cases, when a 
troublesome diarrhoea has yielded to astringents, a very obstinate 
and long-continued state of constipation comes on, apparently con- 
nected with impaired muscular power of the intestinal tube. At 
'first, this confinement of the bowels produces no uneasiness on the 
part of the medical attendant, inasmuch as it is unattended by any 
fulness or tension of the abdomen, and the patient may, in other 
respects, appear to be doing well. After some days, however, it is 
judged prudent to excite alvine evacuations, which is attempted 
cautiously, for the practitioner bears in mind the violence of the 
previous diarrhoea. He therefore chooses mild purgatives at first, 
and next day, finding them ineffectual, he ventures on the exhibi- 

* [Dr. Graves is fully sustained in these views by the results of our experience 
in this country. Laxatives are very beneficial, purgatives are rarely so, and may 
be positively mischievous unless the strength oflhe patient is very good, and 
there is much congestion of the brain. These remarks must not be applied to 
the southern miasmatic fevers, or even to typhoid fever. ' We speak only of 
pure typhus. — £c?,] 



^8 G1LA.VKP8 CLOnCAL LECTURESL 

tion of more active mediciiies, and orders a fineqpiei :r: t . cl ci 

injectioDs. Even these steps fail, and constipatioL : jes far 

several days after the effi>rts to remove it have bee \ T^rsd. 

This is a jonctaTe foil of difficulty. In such cases : : n 

most be osed in employing active cathartics, and gre 

betaken to remove any accomulation of hardene: 

may have accomolated in the rectom or sigmoic r - i 

colon. This most be done partly by the fii^r, or : 

appropriate scoop, as, for instance, a narrow-^KJc: 

tions of soap and water. When no soch mechani: :; is 

exist, to account for the failure of the cathartics, wr : s : : tel 

cantioosly, and not rashly accumalate medicines of f 

in the stomach and bowels of the patient. Tery ac: . r :. 

thoi^h thev fail to stimolate the paralysed bowels s: : t r 

their contents, may yet irritate the intestinal mnc: 5 

and cause destructive inflammation. For this reasc : 

rate doses of colocynth, gamboge, jalap, scammoo; 

have failed, they must not be repeated ; neither, excr 

cases, ought we to administer croion oil internally. 7 i 

salts, senna, magnesia, and above all, castor oil, £ i i 1 

with spirits of turpentine, or uncombined and vt 

repeated, must be our chief internal medicines. In 5 i 

compound decoction of aloes, with small doses of sc : i r* 

ne^a, will succeed io exciting the paralysed bowdis 10 ^ci.oa, 

where other and more powerful pmgatives have failed. Injections 

should be perseveringly repeated, and varied both in quality and 

quantity ; and they should be always thrown as far as possible into 

the bowels, i^ means of a flexible tube and Read's syringe: When 

they are retained, and excite swelling of the belly, as too frequently 

happens in these cases, we mi^t desist from their lee. 

This obstinate state of constipation may be supposed '0 Se^^^d 
on a d^ree of paralysis of the bowels ;^ for usually in s : : _= r s 
an evident paralysis a^cts the bladder, causing reten:: 
sphincters, giving rise to an involuntary dribbling of nrire 

Chi the subject of bleedii^ in fever, I have but very fe is 

to o&r. In the first place, with respect to the po¥Per w : 
section possesses of checking lever, it may be observec. t r 

c^n be no doubt that it has frequently been found capab.^ c: i -^cl- 
ing this purpose, particularly where it has be^i properly employed, 
and in conjunction with other means. I ^leak here with ref^ence 
to casK in which bleeding has been used under &vouralde circum- 
stances, and very soon after seizure — as in students, medical prac- 
titioners, hospital attendants, soldiers, and seamen. In soch per- 
sons, and others whose circumstances have been eqoaUy favouraUe, 
there is 00 doubt that venesection has fifeqoently socceeded in cut- 
ting short fever : and if called to a ease of typhus within the first 
ten or twelve boors after seizure, I should have no faesitatioQ in 
having recourse at once to Ten^ection, fdlowed by an emetic; 
and my own experience convinces me that I dboidd affi>id my 



TREATMENT OF FEVER. 329 

patient a very good chance of escaping the disease. I have on 
several occasions succeeded in arresting the progress of fever by 
these means; and the records of naval and military practice furnish 
many proofs in corroboration of my statements. I have also the 
authority of Dr. Cheyne (whose experience in every point con- 
nected with fever was immense) in favour of the efficacy of bleed- 
ing in commencing fever, as a mode of treatment which has fre- 
quently proved successful in his hands. Bnt it is only in the very 
commencement, and almost only during the stages of rigor, that 
you can hope to derive any advantage from venesection in cutting 
short an attack of fever. I do not mean to say that you have in 
typhus, as intermittent, distinct rigors, lasting each for half an hour, 
or even longer; by the stage of rigor in typhus, I mean to designate 
the period o[ formation, during which the patient complains of 
recurrent chills, although his skin feels hot to the touch when 
examined by another person. This stage lasts generally from 
twelve to twenty-four and in a few cases to thirty-six hours; and 
it is only during this stage that you have a chance of extinguishing 
the fever at once, by the abstraction of blood from the system. 

You may also have recourse to venesection within the first day 
or two, for the purpose, not of arresting fever at once, but of lower- 
ing inordinate vascular action, in persons of a robust habit, and 
where the fever sets in with violent headache, great heat of skin, 
and a firm bounding pulse. We do not, however, at present meet 
with many such cases, nor are we often called in at a period when 
venesection might be advantageously practised. The physician 
seldom sees a case of fever until the third or fourth day, and then 
it is too late to think of general depletion by the lancet. This 
explains why venesection is so seldom employed in typhus in our 
hospitals. Moreover, in entering on the treatment of any case of 
fever at present, you should bear in mind the nature of the prevail- 
ing epidemic, and be careful how you proceed with respect to 
bleeding ; and if you take away blood, do not go so far as you 
would if treating a case of fever under different circumstances, and 
of a genuine inflammatory character. I know that many persons 
have asserted that you can bleed in all cases of fever, no matter 
what the state of debility may be; because this, they say, is only 
apparent, and depends upon congestion and oppression of vascular 
action. I do not know how far this doctrine may be applicable to 
other epidemics, but in the present fever it certainly does not hold 
good ; and no man in his senses would think of adopting it as a guide 
for his practice. I have seen some of the most intense, dangerous, 
and protracted cases of fever, commence without any appreciable 
increase of vascular action, with a soft, slow pulse, a cool skin, no 
symptoms of congestion of any internal organ : in fact, without any- 
thing which would, even in the youngest and most robust habits, 
call for the use of the lancet. Increased vascular action, and this 
you should always bear in mind, is not in itself a proof of an 
inflammatory diathesis in fever, but rather one of a set of symptoms 

28* 



330 GRAVES'S CLI?fICAL LECTURES. 

prodoced by the same morbid cause. The heat of the skin and 
rapidity of pulse are. just like the debility, products of the same 
morbid cause, and not the results of inflammation, or increased 
action ot the heart, depending on a general inflammatory condition 
of the whole mass of the blood. You should also recollect that 
in fever, as well as in other diseases in which the nervous system 
is greatly deranged, the pulse is not unfrequently a very deceptive 
guide. In many cases of fever, where the patient happens to be of 
an irritable habit, the pulse exhibits a degree of thrill and apparent 
hardness, which might lead an inexperienced or inobservant prac- 
titioner into serious errors. I do not mean to say that an inexpe- 
rienced finger will not be able to distinguish a pulse of this kind 
from one of genuine hardness, but I know that many persons have 
been misled by it, and I warn you against the danger. 

Again, never use the lancet when there is any, even the slightest, 
appearance of maculae, no matter how intense the headache, heat 
ot skin, or signs of general vascular action, may be. I have seen 
some cases in which the lancet was used during the presence of 
maculae, and I have seen its employment followed by the most 
lamentable consequences. You should, therefore, never omit to 
examine the skin, for circumstances might occur which would 
authorise a moderate use of the lancet, provided there was no 
sign of maculae present. Formerly, persons were very much in 
the habit of employing arteriotomy when the headache and deli- 
rium were violent, regardless of the period or stage of fever; and 
nothing w^as m.ore common than to see a physician ordering the 
temporal artery to be opened on the eighth, ninth, or even tenth 
day. This was very much the practice during the time when the 
doctrine of typhus being the result of inflammation of the brain 
prevailed in this country and England, and a very unsuccessful 
practice it was. You perceive we seldom have recourse to arte- 
riotomy here ; it may be occasionally necessary, and when it is, 
we employ it ; but as a general practice it does not appear entitled 
to any merit, nor can we give it our recommendation. 

The examples which you have seen in hospital show you that 
local inflammation arises, generally speaking, at a period when 
general bleeding is no longer admissible. Here you must have 
recourse to cupping and leeching ; and this leads me to say a few 
words on this part of the subject. I have observed that local 
inflammations in typhus are most usually seen after the stage of 
excitement has arrived at its acme, and that it is generally about 
the middle of fever that they begin to fix themselves in various 
internal organs. We have, it is true, very severe affections of the 
internal organs, particularly of the brain and digestive system, in 
the commencement of fever, but these are most frequently the 
results of mere irritation or excitement, and not of true inflamma- 
tory action. They are, however, of considerable importance, and 
frequently require the application of leeches. I have spoken already 
of the mode in which leeches are to be applied to the head, with 



TREATMENT OF FEVER. 331 

the view of relieving headache and cerebral congestion ; it is not 
necessary that I should say anything respecting iheir application 
to the epigastrium or abdomen, for the relief of gastro-inlestinal 
symptoms, in the beginning of fever, as there is very little chance 
of your doing any mischief, even by the free use of leeches, at this 
period ; it only remains for me to make a few remarks on the use 
of leeches and cupping-glasses, in the more advanced stages of the 
disease. Well ; your patient, suppose about the ninth or tenth 
day, gets pain in his side, cough, and increased frequency of respi- 
ration, and, on examination, you find sufficient evidence of the ex- 
istence of pneumonia. Or he complains of abdominal symptoms, 
and you have strong reasons to think that hepatitis or enteritis is 
present. Here 3^ou will have recourse to leeches or cupping, ac- 
cording to the circumstances of the case. An attack of pneumonia, 
coming on in fever, frequently acts as a stimulus to the economy r 
the collapse of fever disappears more or less, and the pulse becomes 
more firm and resisting. This is a fortunate occurrence, for under 
such circamstances the patient is better able to bear depletion, and 
you may proceed at once to apply cupping-glasses or leeches to 
his chest, regulating the quantity of blood you abstract not only 
with reference to his present symptoms, but also to his future con- 
dition. But it sometimes happens that pneumonia occurs at a later 
period of the disease, and when you cannot use cupping-glasses, or 
even leeches, to any great extent. In such cases,, (and the same 
remark will apply to enteritis, or any other inflammation occurring 
in the advanced stage of fever,) you should leech with great cau- 
tion ; begin with four or six at a time, and when they drop off, cover 
the leech-bites with a cupping-glass. In this way you will know 
pretty nearly the exact quantity of blood which the patient has lost, 
and you can arrest it with less difficulty afterwards. You can then 
have recourse to calomel and opium, or tartar emetic, according 
to circumstances. Leech as far as you can, and then have recourse 
to immediate blistering, and such other means as the exigencies of 
the case may demand. 

You may leech, then, freely, and without any particular caution, 
in the commencement of fever, whether it be for cerebral, or for 
thoracic, or abdominal symptoms; but as the fever advances, you 
must exercise more discrimination and care, both as to the number 
of leeches you apply, and the time you allow them to bleed. In 
applying leeches to the head, I would advise you not to put them 
on both temples, or behind both ears at once, as this is awkward, 
and prevents the patient from lying on either side. You may also^ 
in cases of cerebral irritation, apply them to the nostrils or septum 
narium ; in this way you will be able to get away a large quantity 
of blood by means of very few leeches, for one or two at a time 
will be sufficient. The application of leeches to the abdomen or 
thorax, so far as the place for their application is concerned, does 
not require any observations. You will frequently have to employ 
them in the treatment of gastro-intestinal inflamnaation, and you 



g32 GRAVES'S CLINICAL LECTURES. 

will find them most valuable agents in many cases, when scarcely 
any other mode of depletion is admissible. In leeching the chest 
and abdomen in particular, I would advise you never to have 
recourse to fomentations with the view of getting more blood from 
the leech-bites. Fomentations are too often a source of fresh mis- 
chief in cases of this kind, leading to exposure of the patient to 
cold, and to the annoyance of having his linen and bedding kept 
wet for hours together. Always give directions to have cupping- 
glasses, or hot dry flannel cloths, applied as soon as the leeches 
drop off, and you will avoid the inconveniences attendant on 
fomentations, at the same time that you will be able to procure 
quite as much or even more blood, within the same space of time, 
and you will have less difnculty in arresting its flow afterwards, a 
point of some importance in cases where the loss of even a trifling 
quantity of blood is often of great moment, and likely to have a 
very powerful erlect on the state of the patient. 

I had purposed concluding to-day my observations on the prin- 
cipal remedial agents used in the treatment of fever, but find that 
time will not permit me to go further. At our next meeting, I shall 
say a few words on the employment of mercury, and some other 
remedies, and will then proceed' to the consideration of some cases 
of importance which are now under treatment in our wards. 



LECTURE X. 

Abdominal aneurism — Effect of posture on the bruit de soufflet — Limitation of this 
sound to one spot in aneurism — Its extension in mere nervous affections — Letter 
from Dr. Corrigan on the subject — Case of diabetes — Discovery of casein in the 
urine — Different rarieties of diabetes. 

I SHALL draw your attention to-day to the consideration of some 
cases which occurred before the commencement of the present 
session — that is, during the months of August, September, and 
October — and which were attended with circumstances of peculiar 
interest. 

The first of these cases was one of aneurism of the abdominal 
aorta, a disease which has been studied with much care and atten- 
tion within the last few years. It is unnecessary for me to enter 
here into any detail of the symptoms and morbid phenomena which 
characterise this affection; you will find sufficiently ample accounts 
of them in various works of pathology ; the chief symptoms you 
will find briefly but accurately given in Dr. Cowan's excellent 
** Bedside Manual of Physical Diagnosis." Ten or twelve years 
ago, the diagnosis of this disease was extremely obscure and imper- 
fect, and an aneurism of the abdominal aorta was rarely detected 
in its incipient or even in its advanced stage, when it did not pre- 



TREATMENT OF FEVER. 333 

sent the phenomena of a large pulsating tun:iour, the existence and 
nature of which could be scarcely passed over even by the most 
superficial observer. In the commencement, when the aneurismal 
tumour was small, and did not manifest itself by any external pul- 
sation, or even when it was of considerable size, but happened to 
be protected from an examination by its situation, connections, &c», 
it not unfrequently remained undiscovered during the patient's life- 
time, and was detected only on dissection. A very remarkable case 
of this description has been recorded by Dr. Beatty, in the 5th vol. 
of the Dublin Hospital Reports. The patient was a relative of my 
own, and I had frequent opportunities of studying his case. I did 
not see iiim in the commencement of his illness, but I afterwards 
accompanied him to London and Paris, where he had the advice of 
the most eminent professional men. He died about two years after- 
wards, and it was only on dissection that the nature of his disease 
was discovered. The case was subsequently published by Dr. 
Beatty, chiefly from the gentleman's own notes, and excited a great 
deal of attention in London and Paris, as well as here. I mention 
these facts to show you that it is only very recently that aneurism 
of the abdominal aorta has been studied properly. I feel perfectly 
convinced that an error in diagnosis of this description would not 
be committed at present, and that, with the light which we now 
possess, the disease would have been speedily recognised. You 
will find the case in the 5th vol. of the Dublin Hospital Reports, 
and it is well worthy of your attentive perusal. 

I do not intend to enter into any general considerations on the 
subject of aneurism of the abdominal aorta ; I shall confine myself 
at present to the examination of a single point of diagnosis, on 
which Dr. Corrigan has published some observations, in a recent 
number of the Dublin Medical Journal. With the view of illus- 
trating this matter more fully, I shall read for you the notes of the 
following case. 

Michael Whelan, a gardener, aged 40, was admitted into the- 
Meath Hospital on the 19th of August, 1836. He had no remark- 
able illness, except an attack of venereal about nine months pre- 
viously, for which he was salivated and cured. His health con- 
tinued as good as usual, until about five months before admission, 
when he was attacked with pain in the stomach and bowels, and 
occasionally in the back and right hypochondrium. About six 
weeks before admission, this pain became constant, and was accom- 
panied by epigastric tenderness, nausea, and vomiting. For these 
symptoms he was admitted into Sir P. Dun's Hospital, where he- 
had leeches, sinapisms, and blisters, to the epigastrium and right 
hypochondrium, and internally, turpentine, with castor oil, but 
without any benefit whatever, and he left the hospital pretty much 
in the state he entered it, about four days before he was received at 
the Meath. His symptoms, on admission, were pain and tender- 
ness on pressure over the epigastrium, pains shooting through the 
whole abdomen, no tumour or hardness disco verable^ anorexia^ 



334 GRAA'ES'S CLESICAL LEUTUEES. 

Daasea, with occasional vornitiDg. Tongue clean, bowels free, no 
thirst He complained of loss of sleep, bis spirits were dejected, 
and there was more or less emaciation ; pulse 102, full and regular; 
action of the heart normal. He stated that he generally obtained 
transient relief from the abdominal pains by taking a draught of 
warm water. 

From the history of this case, and the consideration of the 
patient's symptoms, we are led to conclude that it was a case of 
dyspepsia. You percei^-e he had many of the symptoms which 
characterise derangement of the digestive system — as anorexia, nau- 
sea, with occasional vomiting, epigastric tenderness, pain, and 
emaciation ; and in addition to these, there was no tumour or hard- 
ness present which would lead us to infer the existence of organic 
disease. We therefore had recourse to the usual remedies emploved 
on such occasions. We ordered a large enema of warm water and 
oil, to be thrown up the rectum with the aid of Read's syringe. 
This treatment is generally employed on such occasions, whether 
the patient reports his bowels costive or not ; for we have frequently 
observed, that after using enemata in this way, once or twice daily, 
for three or four days, many of the usual phenomena of indigestion, 
as pain, nausea, irregularity o{ bowels, and abdominal tenderness, 
are greatly relieved, or disappear altogether. We also applied 
leeches to the epigastrium, and prescribed hydrocyanic acid, to be 
taken in doses of two drops, three times a day. Under this treat- 
ment, assisted by a carefully regulated diet, the patient seemed to 
improve at first, and experienced some relief of many of his distress- 
ing sensations. His pulse fell to 84, and subsequently to 76, and 
the vomiting ceased : but the pain in the epigastric and umbiHcal 
regions continued to recur at intervals, sometimes depriving him of 
sleep, and at the same time when we expected a favourable result 
from our treatment, he would suddenly, and without any apparent 
cause, become as bad as ever. On the 24th, Mr. Harnet, a pupil in 
this hospital, noticed a feeble and indistinct pulsation in the epigas- 
tric region, and, on applying the stethoscope over this part, a distinct 
bruit de souffiet was beard, which diminished in intensity as the 
instrument was carried downwards, ceasing altogether at the 
umbilicus. Under these circumstances, I requested my friend Dr. 
Corrigan to examine the patient, which he subsequently did, and 
gave the diagnosis of aneurism of the abdominal aorta. He found 
the bruit very distinct when the patient was in the recumbent 
position, but it nearly ceased when he sat up or stood erect. By 
elevating the pelvis, and depressing the shoulders, a /remissement 
was felt once or twice when deep pressure was made in the imme- 
diate neighbourhood of the place where the bruit was heard. 

The man continued to suffer in various ways during the time he 
remained in hospital Sometimes he was quite free from pain, had 
a tolerable appetite, and improved in his looks and spirits. At other 
times, he had severe attacks of pain in the stomach, accompanied 
with nausea and severe pain in the spine, aboat the termination of 



1 



BRUIT DE SOUFFLET. 335 

the dorsal vertebrae. When the pain in his stomach was severe, 
the pain in the back was generally relieved. These pains fre- 
quently afTected him during the day, but the most usual, as well as 
the severest paroxysms, occurred at night. He suffered some incon- 
venience and sense of weight and fulness after eating, but this was 
by no means a prominent symptom. He also had occasional fits 
of emesis, and generally felt more or less relief after vomiting. 
Towards the latter period of his illness, the paroxysm of pain be- 
came more frequent and severe, and lasted for a longer period. 
On the 16th and I7th, he had acute pain in his back and stomach, 
accompanied with nausea. On the 18lh, he was seized with 
violent pains while eating his dinner, and expired about half-past 
five in the afternoon. 

His body was examined by Mr. Porter, eighteen hours after 
death. On opening the abdomen, an aneurism of the abdominal 
aorta, immediately below the cjeliac plexus, was discovered. It 
was evidently a true aneurism, and originated in a dilatation of the 
coats of the vessel with rupture, for the lining membrane of the 
artery was continued into the aneurismal sac, from which, also, 
several branches were given off. The edge of the aperture, 
through which the blood escaped into the cavity of the abdomen, 
was very thin, and presented a fringed appearance. There was 
an immense quantity of coagulable blood effused, which adhered 
firmly to the sac, and also to the kidney. The aneurismal sac was 
about the size of a hen's egg^ or a little larger. The external ihac 
arteries were diminshed in size. 

Some time after this case had been examined by Dr. Corrigan, he 
favoured me with the following communication : — 

" My dear Doctor, — I thank you for your kindness in having 
given me an opportunity of seeing the case of Whelan, who died in 
your hospital of aneurism of the abdominal aorta. You have ex- 
pressed a wish that I should explain on what grounds I gave the 
diagnosis of aneurism, which chanced to turn out correct. On the 
symptoms I have nothing to observe ; they simulated, as well as I 
can recollect, the ordinary symptoms of chronic gastro-enteritis. 

" The opinion which I gave was altogether founded on the phy- 
sical signs, viz., the permanent existence of bruit de soufflet, the 
remarkable increase of the sound by change of position, and the 
limitation of the sound (when thus increased) to a particular spot. 

•« The bruit de soufflet was heard a little below, and to the left side 
of the ensiform cartilage ; it was indistinct when the patient stood 
up or sat erect, but when he was made to lie in a perfectly hori- 
zontal position, the sound became very loud, and with the increase 
of loudness it became the more evident that it was quiet circum- 
scribed, and that it did not extend downwards along the aorta. 
This case made the third of abdominal aneurism which I have 
seen at so early a period of the disease, and in the Dublin Medical 
Journal for January, 1833, where I have related the two previous 



§36 GRAVES'S CLINICAL LECTURES. 

cases, I have endeavoured to explain the principle on which I have 
used change of position as a means of rendering distinct a bruit de 
soufflet which might otherwise escape detection. While a patient 
with aneurism of the abdominal aorta sits or stands erect, the 
column of blood in the descending aorta is exerting a considerable 
hydrostatic pressure upon the sides of the aneurism, w'hich, even 
in the intervals of the heart's contraction, is sufficient to keep the 
aneurism very tense. The sides of the aneurism thus kept tense 
cannot thrill or vibrate, and hence there is little or no bruit de 
soufflet ; but when the patient is placed in a horizontal position, 
the aneurism is relieved of the hydrostatic pressure, and being no 
longer constantly acted upon by a force which would keep it very 
tense, its sides are more at liberty to vibrate, each new rush of 
blood gives to the now comparatively flaccid side of the aneurism a 
thrilling vibration, and the bruit de soufflet becomes proportionally 
loud. In the latter pages of the article on Bruit de Soufflet, which 
I have sent for insertion in the November number of the Dublin 
Journal, I have endeavoured to explain the rule which regulates 
the connection between aneurism and bruit de soufflet. 

" There are cases of bruit de soufflet in the abdominal aorta, in 
which the sound arises from nervous irritation or other causes, and 
which sometimes simulate aneurism ; but in all such cases which 
iiave come under my own observation, it could be perceived that 
the bruit de soufflet extended along a considerable portion of the 
aorta, and in most of the cases the vessel could be traced of its 
natural size. Laennec, you remember, has already made a similar 
observation. ' Le stethoscope me donnait la sensation de la forme 
et des dimensions de I'artere, dont le calibre semblait tout a-fait-egal, 
et de grandeur naturelle,'^ &c. 

" It remains, of course, for further observation to confirm or cor- 
rect the principle on which change of position was used to assist in 
forming the diagnosis. Excuse me for trespassing on yourpatience 
with this long letter, and . j 

" Believe me, my dear doctor, 
" Yours sincerely, 

"D. J. CORRIGAN.'^ 

Youperceive, then, that Dr. Corrigan dwells on the circumstance 
of bruit de soufflet being heard louder in the horizontal position, 
not because he thinks it a diagnostic of aneurism of the abdominal 
aorta, but because a knowledge of this fact leads us to the discovery 
of bruit de soufflet in cases where otherwise it would be very likely 
to escape observation. Thus, according to his views, it will not be 
sufficient, in a case of suspected abdominal aneurism, to examine 
the patient standing, or in the erect position; you must place him 
in the horizontal position, in order to hear the bruit distinctly, and 
if you depress the shoulders, and elevate the pelvis, so as to dimi- 
nish still farther the hydrostatic pressure, you will render the sound 
still more distinctly audible. When Dr. Corrigan first published 



BRUIT DE SOUFFLET. 337 

his views, I fell into the error of supposing that he intended to put 
this forward as a diagnostic mark between aneurism of the abdo- 
minal aorta and diseases which simulate it. This, however, is not 
the case ; Dr. Corrigan's meaning is, that the change of position 
will enable you to discover a bruit de soufflet, which, under other 
circumstances, could not be detected. He afterwards proceeds, as 
yo.u may have observed, to distinguish the bruit de soufflet of 
aneurism from that which accompanies other affections, and his 
chief diagnostic is the limitation of the bruit de soufflet to a par- 
ticular spot of the track of the artery. In cases of nervous irrita- 
tion, accompanied with bruit de soufflet, you hear the bellows 
murmur all along the course of the vessel ; but in the bruit de 
soufflet of aneurism, the murmur is confined to a certain spot, and 
becomes more indistinct the farther you remove the end of the 
stethoscope from the place where it is situated. I would refer you, 
for farther information on this point, to Dr. Corrigan's paper on 
bruit de soufflet, in the Dublin Journal for November, 1836, where 
you will find enumerated all the causes which Dr. Corrigan looks 
upon as capable of giving rise to this peculiar variety of sound. 

Shortly after Whelan's death, another case offered itself to our 
notice, which promised to throw some further lighten the subject 
of aneurism of the abdom.inal aorta. A woman named Sarah 
Smith, aged 48, was admitted into the Meath Hospital on the 23d 
of September, 1836. She stated that she had been ill for three 
months, and complained of headache, pain and weakness of the 
loins, loss of strength, and palpitations of the heart. Her appetite 
was impaired, her stomach irritable, and for a considerable length 
of tim.e she had been subject to attacks of vomiting, in which she 
threw up large quantities of sour fluid. Her bowels were habitually 
costive, and consequently required the stimulus of purgatives. She 
had frequent rigors, followed by heat of skin and perspirations, 
which sometimes attacked her two or three times a day. The 
pain in the head was chiefiy confined to the occipital and mastoid 
regions; she had some tenderness on pressure in this situation, but 
no appearance of swelling. She complained of slight cough, 
aggravating the headache, but on examining the chest no morbid 
sound could be discovered, and the action of the heart appeared 
healthy and normal. The abdomen was soft and natural, but on 
applying the stethoscope over the epigastric region, a loud distinct 
bruit de soufflet was heard when the patient lay in the horizontal 
position ; this sound became altogether indistinct when she stood 
or sat erect. Owing to the emaciated state of the palient, and the 
thinness of the abdominal parietes, the aorta could be felt quite 
plainly throughout nearly its entire course. It appeared to run 
rather tortuously, but no evidence of any kind of dilatation could 
be discovered. The patient had no pain in the epigastric region, 
but had constantly suffered from a sense of tightness in this situa- 
tion. She complained, however, of constant pain in the spine, 
about the upper part of the lumbar region. The catamenia had 

29 



338 GRAVES'S CLINICAL LECTLTIES. 

ceased, and she was subject to a leucorrhosal affection of some 
years' standing. Her tongue was clean, her appetite bad, bowels 
confined, no remarkable thirst or nausea ; pulse 76, weak, but 
regular. 

Her bowels were kept open with rhubarb and magnesia, and 
subsequently with pil. aloes cum asafoetida, and her diet properly 
regulated. Under this treatment she improved rapidly, and left 
the hospital greatly relieved on the oth of October. In this case, 
the bruit de soufflet was nearly, or altogether, permanent ; for it 
could be heard still at the period when the woman left the hospital. 

It extended along the track of the vessel, and depended, most pro- 
bably, not on aneurism^, but on nervous irritability, combined with 
dyspepsia. The woman was greatly emaciated, and we could feel 
the artery distinctly for nearly its entire course, but could not detect 
anything like an aneurismal tumour. I may observe, also, that in 
this case a phenomena was observed, which was also noticed in 
the case of Whelan. Mr. Dillon observed that when the woman 
lay ou her face, the bruit de soufflet could be heard on the left side 
of the spinal Column, but not on the right. 

From a consideration of this case, you will perfceive that change 
of position, as employed hij Dr. Corrigan, is applicable not only 
to cases of bruit de soufflet connected with actual disease of the 
aorta, hut also to cases in which the bellows murmur depends on 
nei^vous irritation. When this woman stood or sat up, no morbid 
sound could be heard ; but when she lay in the horizontal position, 
a loud and distinct bruit de soufflet was heard along the track of 
the artery. The same observation will apply to hysterical bruit de 
soufflet, which is increased in the horizontal, and diminished in the 
erect position; and the very same arguments which Dr. Corrigan 
has used to explain this sign in aneurism of the abdominal aorta, 
will apply to other cases in which there is bruit de soufflet without 
aneurism. 

Having: made these observations, I shall proceed to direct your 
attention to a very remarkable case of diabetes, now under treat- 
ment in the chronic ward. When the patient was admitted, he 
complained merely of emaciation, weakness, and thirst; and as we 
could not find anything to account for the last symptom, I 
requested the gentleman who had charge of the case to attend care- 
fully to the state of the urinary secretion, as I suspected it was a 
case of diabetes, which afterwards turned out to be the fact. On 
examining the urine, shortly after his admission, no urea could be 
found in it; within the last two days, it has been analysed with 
great care by Dr. Aldridge, and he informs me that at present it 
contains a considerable quantity of urea. You perceive, then, that 
the result of our treatment has been favourable; the urea, which 
had disappeared while the disease had existed in a more intense 
state, is now beginning to return. Dr. Aldridge has not been able 
to discover any sugar in this man's urine, but he has found it in a 
peculiar animal matter, the existence of which, in the urinary 



DIABETES. 339 

secretion, is worthy of attentive consideration, and presents some 
points of great physiological interest. I may observe, that some 
time before Dr. Aldridge made his analysis, it was reported to me 
that the man's urine was albuminous — a fact which did not at all 
surprise me, as the presence of albumen has been frequently 
observed in the urine of dropsical and diabetic patients, and it has 
been observed' that in some cases of diabetes melliius, the sugar 
became replaced by albumen in proportion as the disease declined, 
and that this process went on for some time after the diabetic 
symptoms continued to diminish in intensity. But in the present 
instance, Dr. Aldridge has discovered that the animal matter con- 
tained in our patient's urine is not albumen, but casein. It may 
be necessary, for the benefit of the younger students, to state that 
casein is not precisely analogous to cheese ; it is, however, the 
principle from which cheese is formed, after it has undergone cer- 
tain chemical alterations, the most important of which appears to 
be fermentation. Casein, as you will find in your works on 
chemistry, is in its chemical composition closely allied to albumen ; 
indeed, the chemical relation is so very strong, that you might be 
inclined to say that the difference between them was altogether 
unimportant, since analysis has failed in detecting any remarkable 
difference in the ultimate elements of which both are composed. 
They certainly differ very little in their ultimate principles, but 
then they differ so much in their properties, that it is to the latter 
alone we must look in order to draw between them a sufficiently 
"well-marked line of distinction. If we examine casein in reference 
to its physical properties, we shall find it very different from albur. 
men. Ferment albumen as long as you like, you will not be able 
to produce anything like cheese; and if the fermented substance 
be allowed to mould and putrefy, it will not produce mites. Again, 
casein is not like albumen, separated from water and precipitated 
by boiling, as is well known from the familiar example of submit- 
ting milk to the boiling process. It is in these, and properties of a 
similar nature, that we discover the difference between casein and 
albumen. 

Nov*' if this discovery of Dr. Aldridge's be confirmed by further 
investigation and experiment, it will form a very remarkable inci- 
dent in the history of diabetic urine. It is also interesting, in a 
physiological point of view, to find the animal principle of cheese in 
the urine of the human male. The only human secretion in which 
it is met with in any considerable quantity, is the milk of the female, 
and also occasionally in the urine of pregnant women — a fact 
noticed by Dr. Cummin, in his able lectures on Forensic Medicine, 
now in course of publication in the London Medical Gazette; 
casein has been also found, in some instances, in the male as an 
abnormal secretion from the mammae. You are aware that Hum- 
boldt has given some instances of this secretion occurring in the 
male, and with the facts which we have before us, there does not 
appear much difficulty in admitting the statements of Humboldt, 



340 GRAVES'S CLINICAL LECTURES. 

when he says, that he has seen an infant nourished for the space of 
twelve months with milk secreted by the male breasts. Here, you 
perceive, we have casein secreted in abundance by the kidneys, 
and you are all aware that sug;ar is secreted by the same organs in 
very remarkable quantities. You perceive, then, we want nothing 
but the oil to make up a secretion from the kidneys analogous to 
that formed in the breasts of the female. Now, when we recollect 
the abundance in which oily particles are present in the blood of 
some dropsical patients, the separation of oil from the blood may be 
easily conceived to be within the power of the kidneys, and, conse- 
quently, it is just within the range of possibility that some of the 
strange tales told about persons passing a milky urine may be 
founded on fact. 

These facts are extremely curious as connected with the history 
of secretion. I think Dr. iildridge's discovery is likely to throw 
some additional light on the nature of diabetic urine, and I am 
happy to find that a new path of investigation has been struck oat 
by a gentleman who has been for a long time a diligent and 
talented pupil in this hospital. 

Before 1 close this lecture, I shall run briefly over the principal 
varieties of diabetes. In the first place, then, we have the diabetes 
insipidus, in which there is merely an increase in the quantity of 
the urine, without any secretion of suo^ar, &c. We had some time 
ago a very remarkable example of this form of the disease in one of 
the porters of Stephen's Green. This man passed generally from 
twelve to fourteen pints of urine in the day. He was treated with 
Dover's powder and vapour baths, and is at present in the enjoy- 
ment of good health, although the disease had continued for many 
months. He still requires,, however, the exercise of much caution, 
for any imprudent exposure to cold, or irregularity of diet, renders 
him liable to relapse. The next form is that termed diabetes mel- 
litus, and is remarkable for the quantity of sugar contained in the 
urine. Then we have the diabetes ureosus, characterised by the 
existence of a large quantity of urea in the renal secretion, and by 
the greater specific gravity of the urine. 'Next we hav^e the 
diabetes albuminosis, in which albumen is found to exist in the 
urine; and lastly, (should Dr. Aldridge's observation turn out to 
be correct,) we shall have to add another species, or the diabetes 
caseosus. It remains, however, for further investigations to decide 
what peculiar modifications of treatment are to be made in those 
various forms of diabetes. At present, we are not quite au fait as 
to the treatment adapted to each particular species of diabetes, and 
much remains to be discovered in a field presenting extensive room 
for speculation and inquiry. 



TREATMENT OF FEVER. 341 



LECTURE XI. 

Fever — Application of cold to the head ; particular apparatus for this — Warm ap- 
plications recommended — Use of mercury in fever — Effects of intemperance — 
Illustrations afforded by particular cases — Necessity of active attention to cerebral 
symptoms — Occasional absence of morbid appearance after death — Contraction 
and dilatation of the pupils — Coup de soleil. 

Let us now return to the subject of fever. 

I have ah'eady laid before you my views as to the use of general 
and local bleeding in fever, and pointed out the circumstances un- 
der which they might be employed. In treating of general bleed- 
ing, I stated that we used it at the commencement of fever, with a 
view of checking the disease altogether, or of rendering it milder 
and less dangerous, by moderating excessive inflammatory action, 
and controlling cerebral excitement. I have also spoken of the use 
of leeches and blisters, and it only remains for me to say a few 
words respecting the application of cold to the head as a means of 
moderating or removing symptoms of cerebrar excitement. In Dr; 
Souihwood Smith's Treatise on Fever, you will find many cases 
and arguments to show that where headache and delirium are pre- 
sent, and where the lancet is inadmissible, if you place the patient in 
a warm bath, and direct a forcible small stream of very cold water 
on his head, he soon becomes more calm, experiences great relief 
of his headache, and is frequently brought back to his bed quite 
free from cerebral symptoms. The burning heat of the skin is 
quickly replaced by a sensation of coolness, or even cold, the flush- 
ing of the face disappears, the delirium vanishes, and a favourable 
crisis is often produced. Indeed, the efl^ects of this remedy are ex- 
tremely remarkable, and I have no doubt that many of the cases in 
which I have employed tartar emetic with such signal advantage 
would derive equal benefit from this mode of treatment. The cold 
afl^usion, as recommended by Dr. Smith, and practised at the Cha- 
rite Krankenhaus, at Berlin, is most certainly an excellent and en- 
ergetic remedy, and I regret that we have not apparatus in this 
hospital for applying it; but I fear its utility must be, at least for 
some time, limited to public institutions, and that it cannot be em- 
ployed to any extent in private practice. There is a good deal of 
prejudice against applications of the kind>in this country. At the 
time that cold aflTusions were used in the treatment of scarlatina^ 
much mischief was done by their indiscriminate employment, and^ 
this added to the general feeling of dislike towards them. At all 
events, cold afl^'usion is a remedy which requires an apparatus^ sel- 
dom at the command of the physician in private families, and, in- 
deed, I think that in most cases we may do very well without it. 

You are all aware, that in cases of determination to the head,, 
the common practice is to shave the scalp, and apply cold lotions. 
In my published Lectures,.! have endeavoured, to point out the inir- 

29* 



342 GRAVES'S CLINICAL LECTLTJES. 

perfect, and even hurtful, mode in which this remedy is ordinarily- 
applied, and to show that it is calculated rather to increase than 
to diminish the heat of the integuments. Cold lotions act as a 
powerful refrigerant, if constantly repeated, so as to keep the part 
below the standard temperature of the body. But this is seldom or 
never done. The nurse applies the lotion, and then, perhaps, drops 
asleep, or occupies herself with some other business, until at last 
she is attracted by the vapour arising from the patient's head, and 
then she renews the application. I need not say that in this way 
all the good effects of cold as a refrigerant are entirely lost, and 
that a degree of reaction is produced which must altogether mar 
and nullify its application. I have, therefore, given up, except in 
very few cases, the practice of applying cold lotions, and give a 
preference to the use of warm fomentations of equal parts of vinegar 
and hot water, applied to the temples and shaven scalp, and fre- 
quently repeated. I am quite sure we employ warm applications 
for the relief of headache and cerebral symptoms much less fre- 
quently than we ought. You are aware that surgeons are in the 
habit of treating some local inflammations with warm, and others 
with cold applications, and that the rules laid down for distinguish- 
ing the cases in which cold, and those in which warm fomenta- 
tations should be used, are deficient in precision, and that most com- 
monly the practitioner has to refer to his own individual experience 
for the guidance and determination of his choice. So it is, also, 
with respect to the use of fomentations to relieve the pain and con- 
gestion of internal parts. Among these, I include determination to 
the head in fever, accompanied by intense headache, restlessness, 
and delirium. In some cases of this description, cold applications 
will give ease ; in others, most relief is obtained by fomenting the 
head with water as hot as it can be borne. 

The idea of employing hot fomentations in cases of this descrip- 
tion was first communicated to me in 1833, by Mr. Swift, who 
became accidentally aware of their value while washing his face 
one day in xery warm water, at a moment when labouring under 
severe headache. The sudden relief obtained by the application 
of hot water, induced him to try it extensively in the headache of 
influenza, and with the most satisfactory results. You are aware, 
that in the influenza which appeared in this country in 1833 one 
of the most remarkable symptom>s was intense headache. This 
was accompanied with great debility, and was not amenable to the 
ordinary modes of depletion. ?sow, Mr. Swift found that by apply- 
ing water, as hot as it could be borne, to the forehead, temples, and 
back of the head, great and almost instantaneous reliefwas obtained, 
and that in this way he was able to keep a most unpleasant symp- 
tom in check, while he was taking measures to remove the disease. 
I afterwards heard from my tViend, Dr. Oppenheim, of Hamburg, 
that he had also discovered that this was the best means of afford- 
ing relief under the same circumstances. This led me to think of 
applying hot fomentations to the head in other diseases, and 



TREATMENT OF FEVER. 343 

although I cannot give you any particular rules for deternnining 
the cases in which you should employ thetn, I can say that you 
■will generally find warm vinegar and water the best and most 
efficacious application in the ordinary headache of fever. 

I shall close this lecture with a few observations on the use of 
mercury in fever, and this will include all [ have to say at present 
on the remedies most generally employed in the treatment of typhus. 
Are we to have recourse to mercury, or not, in typhus? I do not 
allude here to its use as an aperient, but when called to treat a case 
of fever, are you to proceed at once to bring the patient's system 
under the influence of mercury? Are you, in addition to the 
other measures usually adopted in the treatment of fever, to go on 
with the administration of mercury until you affect the mouth, and 
bring on salivation? This was the practice in my time, and great 
confidence was placed in it by the majority of practitioners. It has 
been also very extensively recommended by army and navy sur- 
geons, in the treatment of tropical fevers, which all partake, more 
or less, of the typhoid character. I must confess that I am not at 
all inclined to adopt this practice, and that I have seen abundant 
reasons why I should neither employ nor recommend it. In the 
first place, we have observed in our wards that patients with other 
diseases have frequently caught fever from exposure to infection, at 
a time when they were fully under the influence of mercury. In 
the next place we have observed that persons who were thus 
attacked with fever while in a state of salivation did not escape 
better than others, and that in them the disease ran its full course, 
aggravated rather than diminished in its danger by the pre-existing 
mercurialisation. These facts I have frequently seen verified in 
hospital and private practice. You perceive, then, that mercuriali- 
sation neither protects a man from the contagion of typhus, nor 
does it produce a favourable modification in its type or progress.* 
Again, I have repeatedly witnessed the daily and continued exhibi- 
tion of mercury in fever, and I cannot recollect a single case in 
which it appeared to check the disease, moderate its symptoms, or 
bring about a favourable crisis. I am aware, that in entering my 
protest against this practice, I dissent from a very considerable 
body of my brethren, who from the beginning to the end of fever, 
never cease in their attempts to bring the patient's system under the 
influence of mercury. I am convinced that, -in the cases in which 
recovery is stated to have followed this practice, the post hoc has 
been mistaken for {he propter hoc. Besides, fever is one of those 
aflTections in which you find it extremely difficult, and often impos- 
sible, to bring the system fully under the influence of mercury. 
There are certain states of the system which prevent altogether the 
full operation of mercury, and bad typhus is one of these states. 
Where fever has laid deep hold of the constitution, you cannot 

* [We again express our assent to the author's remark : it is confirmed by 
our own observation. In this instance we again repeat, that the fever in question, 
must not be confounded with miasmatic fevers. — AW.] 




miL§uthsr Hbaa Unlan boC ioi ffe kalxit 

of sme ifliomal fffgauB^ atletagit to hnrng the padieaifs asfi^:^. 

fio iiiiect juisr atfiettoioB to tie case ojf t^ 

wee^ TluBflaueexciieilagooddsalorc 
at the tine^ aad I wU to Bale 90HK fistliBer dhBBenpaii> 

ftedh ia yoar miadsEL 




loi^gdL Ib ikishiw of tie 
totfaed^neof 



TREATMENT OF FEVER. 345 

assumes under the influence of an habitual intemperance; and you 
will often, in the course of your practice, have to endure the annoy- 
ance and disappointment of seeing your patient carried ofl" by some 
new and unexpected malady, after you have succeeded, by infinite 
toil, ingenuity, and patience, in removing every trace of his primary 
affection. 

The case of Murphy was one of those which have been neglected 
in the beginning, where the vantage ground has been lost, and the 
chances of success are diminished almost to nothing. You have 
observed that all the fjital cases of fever which we have had in 
hospital were cases admitted at an advanced period of fever, and in 
which the head had been nes^lected. You have also observed how 
exceedingly difficult it must be to treat cases of this description. 
The patient is admitted at an advanced stage of fever, and at a 
period when he can give no account of his present or past symp- 
toms, or the mode of treatment to which he has been submitted. 
He comes in with delirium, or coma, and subsultus tendinum ; his 
symptoms are certainly cerebral, and he exhibits, perhaps, a blis- 
tered scalp ; but we can have no means of ascertaining whether he 
has had headache, heat of scalp, throbbing of the carotid and tem- 
poral arteries, or vertigo — ^we cannot, in fact, decide with precision 
as to the exact state of the brain, and our practice must be embar- 
rassed by more or less doubt and obscurity. I have already 
impressed upon your attention the urgent necessity of watching the 
head in fever, and I think I cannot too often reiterate the advice 
which I have given you, to endeavour to check cerebral symptoms 
before they amount to any degree of absolute danger. The fate of 
those who have died here, will convince you that when cerebral 
disease has once arrived at its acme, the most energetic measures 
will often fail in arresting it. It is a matter of vital importance, 
then, to prevent this lamentable state of things, and, without wait- 
ing until the symptoms of cerebral disease manifest themselves, to 
anticipate it in its very origin, and thus be enabled to control with 
certainty symptoms which assume such a fearful aspect in cases 
where cerebral disease has been allowed to go on unregarded. 
This is the practical lesson which I wish you to draw from the 
four fatal cases which have occurred in this hospital within the 
last month. 

There are some points in the case of Murphy to which I wish to 
recall your attention, as I am anxious that you should make them 
the subject of reflection. For some days before his death, he had 
been delirious and unmanageable, with total loss of sleep, and a 
contracted state of the pupil. The antiphlogistic and derivative 
treatment had been employed without effect ; and seeing that his 
symptoms were advancing, and his sleeplessness undiminished, I 
ventured to give him an injection, consisting of two grains of tartar 
emetic with ten drops of laudanum.* J am cautious in the adminis- 

* [An opiate enema in cases of fever with stupor and congestion of the head 
should never exceed ten drops. — Ed,'\ 



346 GRAVES'S CLINICAL LECTURES. 

tration of opium in the advanced stage of fever, where there is 
evidence of determination to the head ; and it was on this account 
that I ordered it to be combined with tartar emetic, giving also 
directions that the effect of each dose should be carefully watched. 
He got three enemata during the course of the night — that is, thirty 
drops of laudanum altogether. He dozed after the last injection, 
and appeared more tranquil ; but at our morning visit we found 
him in a state of coma, with rapid sinking of the powers of life, and 
death took place in the course of a few .hours afterwards. I must 
confess the issue of the case gave me some degree of uneasiness at 
the time, as I thought it might have been precipitated by the admi- 
nistration of the opium. I could not say but that even this small 
quantity of opium might have greatly aggravated the cerebral 
symptoms, and accelerated the fatal event. Dissection, however, 
revealed the true cause of death. On opening the brain, we found 
extensive arachnoid inflammation, some effusion on the surface of 
the brain, and an intensely congested state of its vessels. The 
patient, altogether dissipated in his habits, and greatly reduced by 
fever, had been a young man of rather robust constitution previous 
to his illness ; he had been neglected in the beginning of his fever, 
wdiich, from the phenomena observed after death must have been 
characterised by early and decided determination to the brain, 
producing delirium, watchfulness, coma, and a contracted state of 
the pupil, which all our antiphlogistic measures were inadequate 
to remove or control. We did everything in our power: we 
leeched, blistered, and gave tartar emetic, but without effect : the 
case had not come under our care until symptoms of unmanageable 
cerebral disease had been established. This state of delirium, fol- 
lowed by contraction of the pupil and coma, and terminating in 
death, occurs in two classes of cases: first, in hospital patients of 
the lower class, who have been neglected in the commencement of 
fever ; and secondly, in persons in the better classes of life, in wiiom 
the mind is frequently subjected to over-exertion, and who, when 
attacked by fever, exhibit a strong tendency to the early develop- 
ment of cerebral symptoms of a bad and unmanageable character. 
One of the worst symptoms observed in such cases is extreme con- 
traction of the pupil. I have seen the pupil in some cases con- 
tracted to the size of a pin-hole ; and I think I can state, that out 
of all the cases of this description which I have witnessed, there 
"were but tw'o recoveries. I have seen persons who had exceed- 
ingly bad and alarming symptoms of cerebral derangement recov^er, 
although accompanied by great dilatation of the pupil; but I think 
I have seen but two cases recover in which the pupil was con- 
tracted to the small size observed in Murphy's case. 

With these facts fresh in your minds, allow me to direct your 
attention to the case of another man, who died lately in the fever 
ward with cerebral symptoms of an intense character. Now, in 
this man the very same train of phenomena were present which 
we observed in Murphy's case. He had, you recollect, typhus of a 



I 



TREATMENT OF FEVER. 347 

low character, accompanied by delirium, subsultus, and the ordi- 
nary symptoms of determination to the head. 1 could defy any 
man who would compare these two cases together to point out any 
remarkable difference between them. The delirium, nervous ex- 
citement, and watchfulness, commenced the same way in both, and 
ran through the same course; both had contraction of the pupil, 
constant muttering and delirium, persistent watchfulness, and sub- 
sultus tendinum ; and in both the cerebral symptoms terminated in 
coma and death. I would defy the most accurate symptomatolo- 
gist to point out any marked distinction between them. Yet how 
different were the phenomena observed on dissection I In the one 
there was extensive lesion of the membranes of the brain, effusion 
on its surface, and intense congestion of its vessels; in the other, 
there was no appreciable departure from the normal condition. 
These are very strange things, and well worthy of attentive con- 
sideration. But it is not in typhus alone that we meet with the 
occurrence of analogous symptoms — in cases which exhibit a very 
different state of the brain after death. We are encountered with 
the same puzzling contrarieties in many casses of scarlatina. Cases 
come under our notice in which the patients appear to die entirely 
from the violence of the cerebral symptoms, and yet, on examina- 
tion, we find very dissimilar states of the brain. In some, there is 
palpable and fatal lesion — in others, there are some dubious marks 
of congestion, quite insufficient to account for the symptoms ; or 
the brain is found to be perfectly sound and normal. 

It would appear that in scarlatina and fever, the poison of the 
disease exercises a deleterious influence on the brain, independent 
of inflammation, but capable of producing an analogous train of 
symptoms. Hence it is in many instances extremely difficult to 
distinguish the cerebral symptoms produced by the mephitic influ- 
ence of fever on the brain, from those which depend on true in- 
flammation. The one gives rise to delirium and fatal coma as well 
as the other; and in the advanced stage of fever, when the mani- 
festations of nervous energy are feeble and imperfect, and when the 
circulating and respiratory organs act with diminished power, the 
distinction between mere irritation and actual inflammation becomes 
a matter of great difficulty. 

In alluding, on a former occasion, to the occurrence of analogous 
symptoms under opposite conditions of the brain, I noticed that 
headache, tinnitus aurium, and giddiness, have been observed in 
cases where there was distinct evidence of determination to the 
head, as well as where there was every reason to believe that the 
supply of blood to the brain was greatly diminished. You will 
find a very curious illustration of this fact in the last number of 
Guy's Hospital Reports, which contains a very interesting paper 
from Sir Astley Cooper, on the effects produced by tying the caro- 
tid and vertebral arteries. Among other results, it appears that 
when the supply of arterial blood destined for the brain is dimi- 
nished, the animal experimented on becomes stupid, is to a certain 



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ELCX. I 



I 



GOUT. 349 

posed of men in robust health,) then recently arrived at Madras, 
the funeral of a general otficer took place ; to which, unfortunately, 
the men were marched out at an early hour in the afternoon, but- 
toned up in red coats and mihtary stocks, — at a season, too, when 
the hot land winds had just set in, rendering the atmosphere dry 
and suffocating even under shelter of a roof, and when the sun's 
rays were excessively powerful. The consequence was, that after 
proceeding two or three miles, several men fell down senseless. As 
many as eight or nine were brought into hospital that evening, and 
many more on the following day ; three died — one on the spot, and 
two within a few hours. The symptoms observed (and they were 
alike in these three cases) were, first, excessive thirst; and a sense 
of faintness; then difficulty of breathing, stertor, coma, lividity of 
the face, and in one, whom I examined, contraction of the pupil. 
The remainder of the cases, in which the attack was slighter, and 
the powers of re-action perhaps greater, or at all events sufficiently 
great, rallied ; and the attack in them ran on into either an ephe- 
meral or more continued form of fever. The symptoms of these 
three cases did not more closely resemble each other than did the 
post mortem appearances. The brain was, in all, healthy ; no 
congestion or accumulation of blood was observable ; a very small 
quantity of serum was effused under the base of one, hut in all 
three the lungs were congested even to blackness through their 
entire extent ; and so densely loaded were they, that complete ob- 
struction must have taken place.* There was also an accumulation 
of blood in the right side of the heart, and the great vessels ap- 
proaching it." 



LECTURE XII. 

On constitutional inflammation in general — On fugitive swellings and pains — Curi- 
ous case of erratic gout causing transient swellings — Gout aifecting the lobe of the 
ear — Fatty hypertrophy of the ears — Gouty grinding of the teeth — Gouty neuralgia 
of the skin — Remarks connected with Dr. Kingston's recent researches on con- 
sumption. 

I TAKE the present occasion of making a few remarks on certain 
varieties of the gout, of which I have seen several singular exam- 
ples, premising some observations on constitutional inflammation in 
general. 

There is no proposition in pathology better established than that 

* [We have examined a number of cases in which death followed a coup de 
soleil. The brain was but little congested in most of them ; probably not more 
than it would have been in the bodies of other individuals, dying suddenly. The 
lungs and heart were loaded with black blood. This condition, we are disposed 
to believe, was secondary to the state of the brain and spinal marrow, which were 
not inflamed or much congested, but highly deranged in their functions. The 
precise nature of that derangement is not known to us. — Ed.'\ 

30 



350 GRAA'ES'S CLINICAL LECTURES. 

there exist certain constitutional afiectioDS capable of generatics^ 
and modilying local intiammatory aciion: and that local ioflam- 
mations, depending on a coDslitutional cause, are subject lo verj- 
different laws from those which regulate the phenomena of common 
inflammation. 

Another fact of equal importance in many points of view is. that 
local int^ammations depending on a constitutional cause difier re- 
markably from each other, and in general present specific characters 
easily recognised. Thus, local aflections arising from scrofula are 
not likely lo be confounded with those depending on gout or rheu- 
matism, and the inflammations produced by sj-philis and other 
animal poisons exhibit preculiariiies by which their respective origin 
and nature may be satisfactorily ascertained. It must however be 
admitted, that although advanced considerably in our knowledge 
of the phenomena of local disease depending on a constitutional 
cause, the subject still displays a w^ide field for investigation, and 
many points of much importance in pathology and practice require 
still further investigation. Professor Caya), in his Lecons Oraks, 
has made some observations on this subject well worthy of atten- 
tion. Speaking of the dependence of local disease on constitutional 
cause, he says, *• II faut necessairemenl conclure que les degenera- 
tions organiques ne sont pas cause, mais eflet. Et deslors, nous 
sommes fondes a vous dire, qu'au lieu d'user votre vie a chercher 
toujours quelles sont les degenerations organiques et les alterations 
de texture qui produisent les symptomes des maladies, il serait bien 
temps de s'inquieter un peu de savoir ce qui produii ces degenera- 
tions ellesmemes, en etudiant serieusement les caracteres, la marche, 
et la tendance des actes vitaux qui les preparent, et qui les pro- 
duisent reelment.'* 

There is one fact connected with local inflammation depending 
on a constitutional cause not sufficientlv noticed, namely, that cer- 
tain afliections of this kind are sometimes remarkably fugitive and 
transient We are accustomed to regard the process of inflamma- 
tion, whether common or specific, as one which generally lasts for 
some days : but it occasionally happens, that a peculiar diathesis 
will give rise to local affections having the characters of inflamma- 
tion, and which run their course and terminate in the space of a 
few hours. This observation, which should be borne in mind in 
the investigation of diseases connected with the general habit, will 
serve to explain some of the anomalies which strike us occasionally 
in the study of constitutional maladies. The first instance of this 
kind that came under my notice occurred in the case of a florid 
healthy looking boy, a^red six years, in whom, on attentive exa- 
mination, I was led to suspect the existence of a scrofulous taint. 
At the time I saw hini he was subject to a sudden and rapid form- 
ation of bumps, or tumours, on various parts of his body ; sometimes 
on the arms, someiimes on the legs, and occasionally on the trunk. 
These circumscribed tumefactions were accompanied by a feeling 
of heat and tenderness, and apparently depended on local conges- 



GOUT. 351 

tion, or effnsion in the subcutaneous cellular tissue. But what was 
most remarkable in them was, they arose, ran through their course, 
and terminated in the space of four or five hours ; they were sud- 
denly developed, and disappeared with equal rapidity. In the 
course of a month, other more permanent infiamtnations were set 
up; scrofulous ophthalmia, glandular swellings, and ulcers, super- 
vened ; the joints became affected, and the boy died in about a year 
and a half, wilh all the characteristic marks of the scrofulous dia- 
thesis. I have detailed this case before, and shall not dwell on it 
any further at present; but it is well worthy of notice in conse- 
quence of the very brief duration of the first local affections. 

Gout is another disease which occasionally exhibits examples of 
its peculiar inflammation attacking various parts and tissues of the 
body, and that for an extremely short period of time. It is well 
known that persons of a gouty habit are subject to sudden pains or 
twitches, W'hich last only for a few minutes, or even seconds. I 
shall not stop here to consider w^hat may be the nature of these 
fugitive pains ; I may observe, that certain facts seem to prove that 
these pains are the result of a momentary congestion. • Thus, in 
various neuralgic affections, and in inflammatory diseases in which 
the nerves are considerably engaged, pain is suddenly produced by 
coucrhinsj. If a man labours under neuralgia of the frontal or facial 
nerves, or if he be affected wilh sciatica, how are his sufferings 
increased, when he has unfortunately at the same time a cough ! 
Every time he coughs, the affected nerve gives notice that it feels 
the congestion by a sudden pain. Now, the only way in which 
coughing can increase a local pain, is by favouring local con- 
gestion ; that it is capable of doing this is proved by the redness 
of the face it occasions, as also by the hemorrhage from the nose, 
or from recent wounds, which is so often produced by a fit of 
coughing. 

As there can be no doubt, then, that a momentary congestion 
may produce a momentary pain, we may infer that in many 
instances gouty twitches are owing to some cause which determines 
an instantaneous congestion of the aflfected part. Sometimes the 
congestion is more lasting, and then the pain is proportionally 
intense and persistent. Thus Mr. Daly, of Henry street, knows a 
gentleman, the lobe of whose ear is sometimes attacked suddenly 
by gouty congestion, accompanied by agonising pain, but which 
never lasts more than a few hours. 

This fact brings to my mind a curious case which some years 
ago came under the notice of the surgeon-general, Mr. Ferrall, 
and myself A young gentleman of fortune perceived that the 
pendant lobes or tips of his ears were becoming elongated ; they 
increased gradually in such a manner that he considered himself 
disfigured by their unseemly length, and therefore attempted their 
concealment by allowing his hair to grow in long curls, so as to 
hide his ears. This gentleman soon afterwards became dropsical 
and died ; and, on dissection, Mr. Ferrall found his liver in a state 



352 GRAVES'S CLINICAL LECTURES. 

of fatty degeneration. On slitting up the elongated portion of the 
ears, he discovered that their hypertroph}^ had been occasioned by 
the deposition of a large quantity of fal. The subcutaneous adi- 
pose tissue, and the omentum, were likewise much loaded with fat. 
This observation is of some importance, as teaching us that fatty- 
degeneration may be the consequence of a general tendency in the 
system to manufacture and deposit fat in the textures of the differ- 
ent organs. In this point of view the change of structure in the 
liver must be regarded as an effect, and not as a cause, of the 
general derangement of the system, and the fatal termination of the 
case. 

One of the most remarkable instances of fugitive inflammation 
affecting various parts of the body, which has come under my 
notice, occurred in the person of a gentleman lately under my 
care. I shall not go through the whole history of his disease, of 
which he has favoured me with a very minute account, but shall 
merely state, that he is of a gout}^ habit, has had an attack of gout 
in the stomach, and is at present subject to a gouty affection of a 
very extraordinary character. After labouring for some time under 
languor and weakness, accompanied by spasms, pain, and sense of 
weight in the stomach, the pain of the stomach ceases, and his face 
begins to swell at various points, generally commencing on the 
forehead, and involving the cheek and eye, so as to close up the 
latter. He first feels as if a small current of air was directed on 
the face ; then, as it were, the fillip of a finger, or the bite of a gnat ; 
and, on looking in the glass, he suddenly perceives a tumour rising 
on the forehead, which, in the space of half an hour, becomes as 
large as a pigeon's egg, and, as he expresses it, moves down until 
it closes the eye. Sometimes it attacks his lips, and other parts of 
his face, but never affects his nose. These tumours have also ap- 
peared on various parts of his body; and he observes in his letter 
to me, that he is sometimes led to think that they attack his stomach 
also. Before and during an attack of the face, which generally 
occurs on the left side, the discharge from the nostril of the affected 
side ceases. But what is chiefly remarkable in this case is the 
singular character of the local affection. The tumours arise, run 
through their course, and disappear, in the space of a few hours ; 
and on the following day there is no trace of their existence. 
Sometimes the lips, inside of the mouth, palate, and uvula, are 
attacked, giving rise to very considerable inconvenience. Were 
such tumours to occur in the neighbourhood of the glottis, I need 
not say that they would be pregnant with danger of no ordinary- 
character. I ma}^ observe that this gentleman has derived great 
benefit from the use of hydriodate of potash, and from decoction of 
sarsaparilla with nitric acid, and that his health is at present much 
improved. His case presents a very curious example of transient 
local inflammation depending on the gouty diathesis. 

Having touched on the subject of anomalous local affections as 



GOUT. 353 

connected with the gouty habit, I may be allowed to refer to a 
subject on which I have already published some observations. 

In a paper inserted in the Dublin Medical Journal for March^ 
1836, I noticed the morbid habit which some individuals have of 
grinding the teeth, and detailed some facts in illustration of this 
affection. I have now seen several cases of this kind, and I have 
observed that they all occurred in persons of the gouty diathesis. 
The grinding of the teeth continues for years as a daily habit, and 
produces very remarkable changes in the conformation of these 
organs, affecting sometimes one side of the jaw, sometimes both ; 
so that in confirmed cases we frequently find the teeth ground 
down to the level of the gums. There is not at present the slightest 
doubt on my mind, that the irritable state of the dental nerves, 
which gives rise to this- irresistible tendency to grind the teeth, 
depends chiefly on the existence of gout in the constitution. I may 
observe, however, that in many persons in whom the teeth are found 
■worn nearly to the gums, there appears to be another cause in ope- 
ration. Thus, in cases of indigestion, it is not unusual to find the 
enamel of the teeth partially or considerably worn away, long before 
the natural time; and in such instances we used formerly to attri- 
bute the injury to the generation of acids in the stomach. The 
researches of Donne and Thomson, however, have shown that the 
saliva is subject to very remarkable alterations in certain forms of 
dyspepsia, and that whenever the disease is accompanied by much 
irritation of the gastric mucous membrane, and derangement of its 
secreting functions, the saliva becomes extremely acid, and, of 
course, capable of corroding the enamel of the teeth. The follow- 
ing case has recently come under the notice of Mr. Pakenham, of 
Henry street : — 

A gentleman, aged 45, slightly made, but muscular, and born of 
healthy parents, was attacked with shivering and loss of power of 
the right side after a severe wetting. He recovered under appro- 
priate treatment; but about a year afterwards began to observe in 
himself a tendency to grind his teeth, which gradually increased to 
such an extent as to prove a nuisance to himself and every one 
about him. Under these circumstances he consulted an eminent 
surgeon in Dublin, who applied the actual cautery behind one of 
his ears, slightly affected his system with mercury, and extracted 
one of his teeth — all with considerable relief, which lasted for 
about six months. He then became as bad as ever, and applied to 
another surgeon, who tried iron in every form without success ; and 
subsequently to a third practitioner, who used in addition leeching, 
blistering, pustulation with tartar emetic, and various other reme- 
dies, but without any favourable result. All this time his medical 
attendants, so far from suspecting the presence of gaut, ridiculed the 
idea of its existence. 

About three months ago this gentleman came to Dublin, went to 
dine at the house of a friend, and with some others,^ supped late at 
night, and drank some whiskev punch. Next day he had vomiting, 

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f* GOUT. 355 

pains in my limbs, which for the last two or three years I have 
looked upon as neuralgic. Abut a year previous to that time I 
had occasional pains in one foot, which increased so as to become 
violent on one occasion, after a long ride. I had, however, been 
always in the habit of riding, and considered that exercise to agree 
particularly well with my health. Indeed, I had found hunting of 
great use to me, when suffering from liver complaint, having had 
inflammation of the liver twice in my life. It is now fourteen 
years since I had the last attack of liver disease, and 1 very seldom 
have pain in my side ; whenever it occurs, it is generally removed 
by the use of a little blue pill. 

** When first the pains in my limbs commenced they were con- 
fined to my feet ; then, for a long time, extended no higher than 
my knees; latterly they have ascended as far as my hips, where, 
and in the groin, I sometimes experience great suffering. I have 
had occasional twitches in my arms, and very slightly across tlie 
chest. The pain always comes on with sudden violence, which 
renders it very hard to bear, especially when it attacks me during 
sleep. I am frequently aware of its approach, from a general feel- 
ing of discomfiture and depression; from which, in the beginning 
of my complaint, I used to suffer very much for two or three days 
before an attack. These paroxysms have, for four years, shown a 
great tendency to periodicity, recurring generally once every week, 
commencing on Saturday or Sunday, sometimes on Friday, and 
lasting till Monday. They have twice or thrice lasted for a week 
together, but sometimes continue only a few hours. In the com- 
mencement I had occasionally been free from them for two or three 
months together; and within the last year was free from them, at 
two different periods, for a whole month. When in pain, I have 
never experienced the slightest alleviation from anything, except 
at times from a full meal of wine, particularly champaigne. I 
have often been unable to remain in bed, from the violence of the 
pain which is increased by the weight of the bedclothes, or the 
shghtest touch of anything; even the air blowing on the part 
brings on violent torture : at the same time I can bear strong pres- 
sure, or even a blow on the parts, without making me worse. The 
pain appears to be quite on the surface, except that sometimes it 
seems deeply seated, particularly in the ankle-joint and shin-bone. 
It is unaccompanied by any redness or swelling, and flies instanta- 
neously from one limb to the other, rarely occurring in both at the 
same time. It leaves behind great weakness of the affected limb, 
so as to oblige me to walk with a stick for some time, and occa- 
sionally with two. 

" One very unpleasant consequence of the pains in my limbs is, 
that I now find that I cannot use exercise on horseback, if I leave 
it off for any time. I have found this and walking at all times 
conducive to my general health. Indeed I can still walk a good 
deal, even during the attack, although it is very painful, particu- 
larly when setting out. I find it necessary almost constantly to 
have recourse to aperient medicine — generally rhubarb pill. At 



356 GRAVES'S CLINICAL LECTURES. 

times I have had giddiness of my head, and noise in my ears, to a 
very distressing degree; and have had recourse to powerful purga- 
tives, and even bleeding, to remove the symptoms, without effect. 
A medicine, principally nervous, in which gentian was an ingre- 
dient, relieved me at one time after finding the above remedies 
ineffectual. 1 have already tried iron, mercury, nitro-muriatic acid, 
stramonium, arsenic, and the external use of croton oil, without 
benefit, except that I felt rather better for a month after two of 
these remedies, but no longer, and the pain returned with great 
violence at the end of that period. The counter-irritation appeared 
to increase my sufferings. I have also tried anodyne embrocations 
without effect. Anxiety of mind, or annoyance, often brings on 
an attack. I even remarked the other day, that it came on instan- 
taneously on breaking a tooth whilst eating. On the other hand, 
excitement, whether from a sudden necessity for exertion, as on 
occasion of an accident, or anything that gives a pleasing interest 
and occupation to my mind, such as travelling through an interest- 
ing country, seems to keep off, and even sometimes remove an 
attack." 

In general, a regular attack of gout in the extremities is preceded 
by a longer or shorter period of constitutional disturbance and dys- 
pepsia. We must not, however, in making the diagnosis between 
gout and rheumatism, consider this distinction as not liable to 
exceptions, for I have seen more than one case of hereditary gout, 
in which the arthritic attacks came on suddenly, without the slight- 
est precursory derangement of the health, or the operation of any- 
assignable cause. I have as yet seen no instance of a similar 
nature in acquired gout. 

Another exception to the general rule is also worthy of notice. 
In general, a fit of the gout is preceded and accompanied by a 
scanty secretion of turbid high-coloured urine. As the fit goes 
off, the urine increases in quantity, becomes clearer and paler, and 
loses its tendency to deposit the lithates and purpurates. jVow, in 
two cases of hereditary gout, I have seen this order reversed, and 
the approach of the fit announced by a great increase in the secre- 
tion of urine, which was quite watery and limpid, and continued 
so until the violence of the articular inflammation began to decline. 
The urine then became scanty, and deposited the iateritious and 
pink sediment in great abundance. 

That the gouty diathesis may excite its specific inflammation in 
most of the tissues of our organs, is a fact generally admitted; but 
I regret to state that our knowledge concerning the effects which 
it produces in these various tissues is far from being accurate or 
extensive. Beere, M'Kenzie, Middlemore, and others, have done 
much towards elucidating its effects on the eye and its appendages; 
and we are tolerably well acquainted with its progress in serous, 
synovial, and fibrous membranes. What changes it produces in 
the secretions of mucous membranes, is a question which has not 
been studied with an attention commensurate to its importance. 
Thus, though all acknowledge the existence of gouty cough or 



ON PARALYSIS IN GENERAL. 357 

bronchitis, the diagnosis and history of this affection are still very 
inconriplete. This has been acknowledged by Dr. Stokes, who has 
published by far the best account of bronchitis which has yet 
appeared.^ The effects of gout on the lining membrane of the 
urethra and bladder are better known and studied, but I think that 
much still remains to be done in this as in every other class of 
inflammatory diseases where the inflammation depends upon a 
constitutional taint. 

In my published lectures I have long since expressed an opinion 
at variance with that generally taught concerning the bronchitis 
and pneumonia which accompany pulmonary consumption, and I 
have brought forward strong reasons for believing that too much 
importance has been attached, and attention too exclusively de- 
voted, to the tubercles in this disease. Thus authors talk of tuber- 
cular pneumonia, where it would be more correct to designate the 
aflJection as scrofulous pneumonia accompanied by tubercles ; they 
speak of tubercular cavities and abscesses in the lung, in cases where 
scrofulous cavities and abscesses exist. In fact, I repeat it em- 
phatically, that the essential characteristics of phthisis pulmonalis 
are derived from scrofula. This it is which converts what would 
be common into consumptive pneumonia or bronchitis; — this it is 
which so often renders both incurable. 

Tubercles and tubercular infiltration are mere results of nutrition 
morbidly modified by scrofula; they are effects, not causes; they 
often exist without scrofulous inflammation, and the latter may 
exist without them. It gives me much pleasure to find that these 
opinions, which I published two years ago, have received ample 
confirmation from the observations of Dr. Kingston, in a paper 
read before the Royal Medical and Chirurgical Society of London 
in April last, and shortly noticed in the Medical Gazette, April 29th, 
1837. 

At our next meeting I propose to follow up the important subject 
of gout. 



LECTURE XIII. 

On paralysis in general — On paralysis depending on affections spreading from the 
extremities of the nervous system to its centre — Gouty ramollissement of the 
spinal marrow ; two remarkable cases of — History of this hitherto undescribed 
form of disease. 

In pursuing the subject of my last lecture, I shall now turn to 
the consideration of some phenomena connected with the gouty 
diathesis, which possess a much deeper interest, and lead to views 
of far greater importance. I mentioned before, that we frequently 

* See a treatise " On the Diagnosis and Treatment of Diseases of the 
Chest," by Wm. Stokes, M. D. This work places its author among the 
first medical observers of the day, and will acquire for him an European 
fame. 



358 GRAVES'S CLINICAL LECTURES. 

observe flying pains, or twitches, in various parts of the body aris- 
ing from a rheumatic or gouty cause; that in some instances, these 
affections appear to be hmited chiefly to the nervous trunks or 
branches, and that we have thus what may be termed gouty or 
rheumatic neuralgia. We are familiar with rheumatic and gouty 
sciatica, and we know that the history and termination of this 
form of disease often prove it to be inflammation of a specific cha- 
racter, chiefly confined to the trunk of the sciatic nerve. Now it 
is not unreasonable to suppose that this specific inflammation of a 
nervous trunk or branch may, like other inflammations, extend 
farther, so as to involve parts of more importance to the economy. 
What I wish to draw your attention to is this — that in certain cases, 
where gout attacks the nerves, giving rise to gouty congestion or 
inflammation, frequently recurring, and acquiring increased strength 
and deeper root as it proceeds, tjae morbid affection may, after years, 
or even months, run on until it reaches the spinal cord, involving 
a certain portion or portions of that organ, and producing loss of 
sensation and motion commensurate to the amount of spinal de- 
rangement. This is by no means an anomalous occurrence; it is 
merely an instance of disease originating in the periphery of the 
nervous system, passing along the trunk of the affected nerve with 
a retrograde motion, and finally reaching the central parts. In my 
lectures published two years ago, in the London Medical and Sur- 
gical Journal, I pointed out this peculiarity in many affections 
commencing in the periphery of ihe nervous system, and showed 
how the disease extends gradually until it reaches, the spinal cord, 
giving rise to various forms of paralysis. It is too much the cus- 
tom to look upon paralysis as depending upon original disease of 
the nervous centres. I have proved, that, very often, disease com- 
mencing in the nerves of some particular part or organ may be 
gradually propagated to the spine, producing all the symptoms 
which are referable to an original affection of the nervous centres. 
In my lectures on this subject, I have brought forward numerous 
facts in proof of the propagation of disease from the circumference 
to the centre of the nervous system ; and the pathological deduc- 
tions I drew from these facts seem to me to include all the physio- 
logical discoveries made by Miiller and Marshall Hall concerning 
"what the latter terms the reflex functions of the spinal marrow. In 
these lectures I showed that enteritis, arising suddenly in two young 
and healthy persons, from indigestion and obstruction caused by an 
error in diet, was followed in both by well marked paraplegia. I 
instanced, likewise, examples of paraplegia connected with stricture 
of the urethra, and which were relieved by curing the stricture; 
and I detailed cases of acute and chronic affections of the uterus 
and kidneys, which had entailed on the patients, as a remote con- 
sequence of the original disease, loss of the power of motion in the 
lower extremities, sometimes partial and curable, sometimes irre- 
mediable and complete. The cases I am now about to relate form 
a most interesting and valuable addition to those referred to, and 



GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 359 

enable me to carry the principle then advanced still farther, by 
proving that gouty inflammation of the nervea and the neurilema 
may, in process oj time, extend to the spinal marrow and its invest- 
ments, and give rise to derangements of the latter, terminating in 
ramollissement and structural degeneration. 

The subject of gouty degeneration of the spinal cord has not 
been alhided to distinctly by any author with whom I am ac- 
quainted, and is, as far as I can learn, quite new. The deductions, 
therefore, which are drawn from my cases, must, of course, be 
subject to such modifications as may be derived from future expe- 
rience, and must remain to be confirmed by further observation. It 
has been long known that gout may attack the brain, and the 
existence of gouty paraplegia is well known by practitioners who 
have studied attentively the progress of arthritic aftections. Thus, 
in a case which I witnessed some time back, in consultation with 
Mr. Kirby, he prognosed the superv^ention of paraplegia at a time 
when the indications of its approach could not have been disco- 
vered by an observer of les5 experience and sagacity. I have 
already stated that gouty affections of the brain have long been 
known, and I am not sure that some of the older authors may not 
have alluded to gouty affections of the spinal marrow ; but as our 
knowledge of the peculiar state of the brain and spinal cord, termed 
ramollissement, is comparatively recent, and not dating with any 
degree of accuracy earlier than the works of Abercrombie, Rostan, 
and other modern authors, it is obvious that any observations made 
by the older writers, concerning gouty afl^ections of the nervous 
centres, can have no distinct reference to this lesion. The con- 
nection, therefore, of ramollissment of the spinal cord with gout, 
may be considered as now, for the first time, distinctly pointed out. 
As one of the cases which I am about to detail presented an exam- 
ple of the most extensive ramollissement of the spinal marrow on 
record, it would, on this account alone, be especially deserving of 
attention ; but its interest is increased tenfold when placed in juxta- 
position with the second case, so as to exhibit, in a striking point of 
view, the close resemblance observable in the march or progress of 
both, as well as the identity of the lesions discovered after death. 

Mr. , residing in the island of Anglesey, was very much 

addicted to field sports, and, while thus engaged, would occasion- 
ally remain for a whole day without food. He was also very fond 
of angling, and has been frequentl}^ known to wade up to his 
middle in water for many hours together, during very cold weather. 
His general health was good, and his habits were abstemious. In 
1825, when about twenty-five years of age, he had fever, attended 
with inflammation of the joints, and said to be rheumatic : some 
pain and stiffness, and an evident enlargement of the knee-joints, 
remained after the other articular affections had disappeared ; these 
symptoms however yielded, in a few months, to rest and appropriate 
treatment. His health also improved greatly, and he had no com- 
plaint of any kind whatever until the autumn of 1828, when he 



360 GRAVES'S CLINICAL LECTURE3. 

had a slight attack of ordinary cholera, after returning from a 
shooting excursion. In the spring of 1832, he was attacked with 
pain in one foot, supposed to be of a gouty nature : this pain disap- 
peared during a drive of fifteen miles in an open carriage, but a 
certain degree of tenderness rennained, and was always felt, more 
or less, in the part originally affected. He had a similar attack of 
pain and tenderness in the same foot in the following autumn. At 
the time when this attack commenced he was twenty miles from 
home and observed that during his journey the pain became dimi- 
nished as before, and in a few days subsided altogether. In August, 
1833, he had a similar, but much more severe attack ; the pain 
was much more violent than before, and both feet were affected. 
This, however, did not prevent him from following field sports as 
usual; he went on horseback to the mountains to shoot grouse, 
and to this exercise, and drinking a bottle of wine, he attributed 
his speedy, or rather sudden recovery from the pain in his feet. 

Hitherto we have seen a naturally strong constitution struggling 
successfully against exposure to cold, imprudent habits, and a most 
injudicious method of disturbing, or rather repelling, local inflam- 
mation depending on a gouty diathesis. It is not easy to explain 
how it happened that driving in an open carriage, or riding over 
the mountains, so effectually cut short the paroxysms of gout in the 
feet: but it is enough to know that the fits were suddenly and 
imprudently arrested, to be prepared for the consequences which 
ensued — viz., an irregular distribution of the gouty effort, and its 
determination to internal organs. 

In September, 1833 — that is, about a month after the sudden 
^subsidence of the last attack — he was seized with a violent colic, 
accompanied by obstinate constipation. The pain was very severe, 
but he suffered more from a general feeling of restlessness (a rest- 
lessness beyond belief, as he expressed it) than from actual pain. 
He was also greatly annoyed by singultus, and was jaundiced, after 
recovering from the attack of colic. In a lecture already published, 
I have mentioned some cases of jaundice supervening on arthritic 
afTections; in such instances I am inclined to think that it depends 
on rheumatic or gouty hepatitis. In January, 1834, he had an- 
other attack of colic, preceded by a fit, the precise nature of which 
I was unable to ascertain. As these abdominal attacks frequently 
recurred, I shall give a description of one of them, as communicated 
to me by Dr. Llewelyn Jones, jun., his attending physician, a gentle- 
man who justly enjoys a high reputation in his profession. " A 
dull, wearing, and fixed pain would attack the patient in the region 
of the colon : this pain was not increased by pressure, and was 
accompanied by nausea, occasionally by vomiting, and always by 
obstinate constipation. These symptoms were attended by a most 
distressing sensation of restlessness and anxiety. They lasted, on 
one occasion, for three days and nights before I could get the 
bowels opened, when they were immediately mitigated. The pulse 
was never quickened, and in general remained natural ; but if the 



GOUTY RAMOLLTSSEMENT OF THE SPINAL MARROW. 361 

attack was prolonged, it became weak. There never was any 
fever, or any well-marked indication of inflammation in the abdo- 
men. These attacks were always preceded or followed by a gouty 
affection of the feet." 

The attacks in the stomach and bowels recurred frequently, and 
always with the same symptoms, until August, 1835, when a visible 
tremor of the fingers became observable: during some preceding 
attacks he used to complain of weakness of the wrists and pains in 
the fingers, particularly the last joints. As the disease progressed, 
these pains became more intense and extensive, and the torture he 
felt in the hands and arms was beyond description. After August, 
1835, he began to lose the use of his arms, the tremor increased, 
and he began to complain of stiffness about the neck, with great 
restlessness and anxiety. The abdominal attacks came on occa- 
sionally, but not so severely as before. The arms became gradually 
weaker, until the loss of muscular power was complete, and they 
were greatly emaciated ; but Dr. Jones, who had the patient und^er 
his observation until August, 1836, could not detect any evident 
diminution, either in the upper or lower extremities, and the intel- 
lectual faculties remained perfectly unimpaired. In October, 1835, 
two months after the state of the upper extremities had indicated 
the approach of paralysis, the lower extremities became similarly 
engaged : they were affected with tremors and weakness, and in 
the following December the patient had an attack of violent pain, 
with swelling and increased heat in the ball of one foot, which 
was pronounced to be of a distinct gouty character. After each 
attack of pain in the feet, as I have been informed by this gen- 
tleman's sister, the loss of power in all his limbs increased, and 
if he gained a little strength in the intervals between these 
attacks, a recurrence of the paroxysm always made him worse 
than before. 

In February, 1836, I went to Anglesey to visit this gentleman,' 
and saw him in consultation with Dr. Jones and Dr. Williams of 
Denbigh. After a minute examination of the history and symp- 
toms of the case, I declared it to be my opinion that a gouty inflam- 
mation had attacked the nerves of the extremities, and had finally 
extended to the spinal cord and its sheath. I said, that at an earlier 
period of the disease I would have advised salivation by mercur}^ 
but as that was inadmissible under the existing circumstances, we 
should have recourse to other measures. I forgot to state that from 
the commencement of the disease the advice of Sir B. Erodie and 
other eminent practitioners in London had been obtained by letter. 

It would be useless to detail the various general and local reme- 
dies fruitlessly employed in this gentleman's case. He went to 
Liverpool in August, 1836, for the benefit of further advice, but 
finding no relief, returned to Denbigh, where he died in the ensuing 
October. For some time before his death he was greatly ema- 
ciated, and quite paralytic in all his Umbs, but retained his intel- 
lectual faculties entire to the last. His body was examined by Mr. 

31 



362 GRAVES'S CLINICAL LECTURES. 

Williams, whom I had met in consultation in the preceding Febru- 
ary. This gentleman informs me that the viscera of the thorax 
and abdomen were healthy and normal, that no derangement or 
lesion of the brain could be detected, but that the spinal cord oppo- 
site to the last cervical and first dorsal vertebra was softened to the 
consistence of thick cream; the remainder of the cord was also 
softer than natural, but did not present anything peculiar in other 
respects. 

In a letter which I have since received from Mr. Williams, (to 
whose kindness I am much indebted, and to whose zeal and pro- 
fessional skill I can bear ample testimony,) he expresses himself 
with regard to the nature of the patient's disease in a way which 
confirms the views I have taken. He observes, " I once saw Mr. 

' in an attack of gout in the feet about three years before his 

death. There was much pain, and a decided gouty blush. Expo- 
sure in fishing and shooting to a very imprudent degree, while 
under the influence of these gouty attacks, I have no doubt did 
much to render the disease irregular and erratic." 

The fact that the tremors and loss of power commenced in the 
arms two months before indications of paralysis of the lower extre- 
mities appeared, is sufficient evidence to prove that the spinal 
marrow was not the point from which the diseased action proceeded 
originally; for had this been the case, an affection of this organ, 
sufficiently violent to give rise to paralysis of the upper extremities 
so gradual in its progress and so well developed, must long before 
this period have occasioned paralysis of the legs also. There is a 
striking analogy between the progress of the tumours and paralytic 
symptoms in this case and in cases of painter's colic; and the 
analogy likewise holds good as to the violent spasmodic affection of 
the bowels and the constipation observed in both. It is further 
worthy of notice, that in painter's colic the nervous affection is 
accompanied by pain and weakness of the extremities, and ulti- 
mately, although long after the commencement of the disease, by 
spinal tenderness — a fact which has been already noticed by Dr. 
Bright. Again, in painter's colic, as in the disease which I have 
just detailed, the affection of the spinal cord, and the consequent 
paralysis, are evidently subsequent to the disease of the peripheral 
portion of the nerves. 

The next case which I shall now proceed to detail, is* one of 
equal interest and importance. A gentleman of robust frame, aged 
about 55, and having an hereditary predisposition to gout, to which 
his father had been a martyr, and which had exhibited itself in one 
of his sons at the early age of 13, consulted me on the 7th of June, 
1836. Being a man of extensive landed property, he resided chiefly 
in the country, and was in the habit of using much active employ- 
ment and exercise, but indulged rather freely in the pleasures of the 
table. After suflfering much annoyance from dyspeptic attacks, and 
various premonitory symptoms, he had a regular paroxysm of gout 
in the spring of 1828 ; he had a similar one in 1830, and another 



GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 363 

in 1832, each occurring, as before, during the spring season, and 
remarkably severe. During the year 1832 he had several slight 
returns of the complaint, and in January, 1833, he had an alarming 
attack of an enteritic character, accompanied by spasms of the 
stomach and acute pain of the extremities. In the autumn of 1834 
he suffered greatly from a nephritic affection, and got relief after 
passing a considerable quantity of uric acid gravel. In the spring 
of 1835 he had a fall from his horse, and for some time afterwards 
complained of pain in the small of the back and around the trunk. 
He recovered, however, and during the summer and autumn of that 
year remained pretty well ; but in the last week of December caught 
cold, which was followed by severe cough and pains in the chest 
and feet : the latter were then considered to be the effects of gout. 
From this period his health, though often apparently restored, was 
never firm : he became subject to sudden attacks of pain, particu- 
larly in the chest, which gave him much uneasiness. On the 3d of 
June he consulted a physician in his neighbourhood, to whom he 
described his ailment as " a slight pain in the right side, which 
troubled him only a short time before he got up in the morning;" 
this he stated he had felt occasionally for two months before. A 
very careful examination was made over the situation of the liver, 
the place in which he said he felt pain, but no tenderness or swell- 
ing whatever was detected, nor was there any in the direction of 
the spinal cord. His pulse was at this time perfectly regular, his 
bowels natural, and no dyspeptic symptoms existed. He used, by 
the advice of his physician, tonic and laxative pills, and a stimulant 
embrocation. 

When he consulted me on the 7th of June, 1836, I found him 
labouring under what appeared to me to be pleurodynia of an in^ 
termittent and gouty character. During the day he was perfectly 
free from pain, but in the evening the pain commenced, and con- 
tinued with violence until morning. It is unnecessary to detail here 
the various local and constitutional remedies which I employed in 
this gentleman's case, but without any favourable result. From the 
middle of June his symptoms became worse; during the first part 
of the night his pains were very severe; towards morning he usu- 
ally obtained relief by lying on his face, and carefully avoiding all 
motion. About the latter end of July, the pain, which had been 
almost constantly felt at the right side, moved to the left, imparting 
at one time the feeling as if a spear were passing through the dia- 
phragm, and at another resembling the sensation as if these parts 
were squeezed in a vice. When he was in the horizontal position 
this pain was accompanied by a sense of weight; and at times the 
pain would shoot upwards to the clavicles, producing tenderness of 
the intercostal spaces. When the diaphragm was free from pain, 
It most commonly attacked the postero-inferior edges of the scapula, 
and the dorsal region in its vicinity. In August he tried the use of 
the warm bath, and found temporary relief from the first he took ; 
he remained too long in the second, which was heated to the tern- 



364 GRAVES'S CLINICAL LECTURES. 

perature of 100, and nearly fainted. He used the warm bath six 
or eight times, but found no material benefit from it, and could not 
bear the pain produced by the jolting of his carriage in going 
thither. About this time there was a visible alteration in his gait 
and figure : the left shoulder was elevated, his whole frame attenu- 
ated, and his face pale ; he had nearly lost all power of bending the 
spine, and walked with a peculiar stiffness of gait, as if his arms 
■were pinioned. On the morning of the 21st of August he stated 
that he had suffered great agony during the night, and on its abating, 
considerable tumefaction was observable under the right ribs. 
Dyspeptic symptoms now became urgent, his urine scanty and 
turbid ; he became melancholy, and his mind was wholly occupied 
with sad presentiments. At my recommendation he came to town, 
in order to place himself under my more immediate observation, 
and to have the benefit of a consultation. About the 30th of August 
he got, to his great joy, an attack of gout in both feet ; while this 
lasted, which was for about six days, he had complete relief from 
the agonising pains in the diaphragm and chest. The interval of 
tranquillity was, however, but of brief duration ; the inflammatory 
afl^ection of the feet suddenly subsided, and the pain attacked the 
diaphragm with increased intensity. His strength, which had b'een 
rapidly failing, now gave way, and he becamequite paraplegic. About 
the 10th of September the abdomen became engaged, without any 
alleviation of the thoracic symptoms, and he began to complain of 
constipation, tympanites, and abdominal tenderness. The mucous 
membrane of the bladder became next afl^ected ; he had retention 
of urine, with great irritation of the prostate gland, and it was ne- 
cessary to draw off" the water with the catheter several times in the 
day. This state continued from the 22d of September to the 10th 
of November, when the sphincter of the bladder became paralysed, 
and the urine drained off" as fast as it was secreted. During all this 
time the urine continued to present the characteristic marks of the 
lithic acid diathesis in an extreme degree, and contrasted strongly 
with the secretion furnished by the inflamed mucous membrane of 
the bladder, which consisted of a grayish or whitish-yellow, viscid, 
and somewhat puriform mucus, containing either a free alkali, or 
an alkaline carbonate. This secretion was extremely adhesive, and 
hung down in long ropy filaments when the vessel in which it stood 
was inverted. The nature of this mucus was such as to prevent 
any reaction from taking place between its own alkali and the acid 
of the urine. The co-existence of two secretions in the bladder — 
the one alkaline, and the other acid, as observed in this case — is 
extremely curious. 

In this way the patient's sufl^erings went on every day increasing, 
and requiring the most extraordinary care to produce any allevia- 
tion, a task which was discharged with the most indefatigable 
humanity and attention by Mr. Richardson of Sackville street, to 
whom lam indebted for most of the details connected with the 
earlier history of this case. About ten days before his death, the 



GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 365 

extremities, upper, as well as lower, and the trunk, became quite 
paralytic; and from the cervical vertebrae downwards, all power of 
motion and sensation was lost. His voice now became weak and 
inarticulate, deglutition was greatly impeded, and he finally sunk 
on the 27th of November, 1886. 

It may be necessary to state, that, at the time the paraplegia was 
beginning to seize on the extremities, the patient was much annoyed 
by occasional involuntary jerkings of the weakened limbs. This 
morbid action of the voluntary motion had completely ceased. 

This gentleman's body was examined twenty hours after death, 
by Mr. Adams. The body and limbs were greatly emaciated, 
and there were several sloughing sores on various parts of the 
body and limbs, particularly over the scapulae, sacrum, and ileum. 
The brain was perfectly healthy, with the exception of a slight 
effusion under the arachnoid, and into the fourth ventricle. On 
opening the spinal canal, which was done with extraordinary care 
and accuracy, the spinal marrow, from the fourth cervical vertebra 
down to its dorsal termination, was found converted into a morbid 
mass, of an ash-grey colour and pulpy consistence. The theca 
was quite healthy ; but on the first transverse section of it a great 
quantity of yellow serum flowed out, emptying at the same time 
the fluid contained in the fourth ventricle of the brain. When the 
medulla spinalis was slit from above downwards, various shades of 
colour were noticed on the surfaces of the sections. Opposite to 
the third dorsal vertebra a blackish colour prevailed ; and from this 
downwards a yellowish hue was noticed. Two little tumours, 
about the size of filberts, were found attached to the crura of the 
fourth dorsal vertebra ; these, as Mr. Adams remarked, were in all 
probability merely accidental formations. The bladder was very 
much thickened in all its coats, and was so contracted that it could 
not contain more than three ounces ; its internal surface was of a 
dark green colour, approaching to black. The ureters were also 
thickened, the kidneys enlarged, and their lining membrane of the 
same dark colour as the bladder. The pelvis and infundibula of 
the kidneys were dilated, and contained a reddish diseased urine, 
with some puriform matter, the odour of which resembled that of 
the urine passed during the three weeks previous to his death. 
The other viscera did not present anything worthy of remark. 

In order to understand the nature and progress of a disease like 
this, which travelled in a retrograde direction along the nerves and 
their sheaths to the spinal marrow, it may be well to point out 
some of the more striking phenomena by which it was characterised. 
In the first place, the long continuance of the pains at one side of 
the body only is in itself a demonstration that the disease was then 
situated in the peripheral extremities of the nerves, and not in the 
spinal marrow; for it has been well observed by OlHvier, that 
inflammation of the spinal marrow or its sheath can never remain 
confined to one-half of either for more than a very limited period. 
Indeed, so narrow is the cavity in which these parts are contained, 

31* 



366 GRAVES'S CLINICAL LECTURES. 

and so intimate is the connection of their constituent parts, that it 
is quite impossible for inflammation to remain more than a few- 
hours, or at most a day or two, confined to either side. 

Some facts connected with disease of the spinal vertebra, and 
the pains accompanying the progress of that disease, may appear 
to contradict this view of the subject ; for in vertebral caries pains 
are often felt at one side, or in one limb — nay, they often cease, or 
seem intermittent. Now, in order to explain this we have only to 
recollect that here the inflammation does not commence in the 
spinal marrow or theca, but in the bones, and that the nerves, after 
their exit from the spinal cord, are affected in all cases before the 
cord itself. The reason is obvious ; the affection of the nerves is 
secondary, and solely derived from their proximity to the inflamed 
bone and investing tissues ; and consequently the nerves on one 
side may be effected, while the corresponding nerves on the other 
side escape for the time, and until the disease in the bone extends 
itself to their neighbourhood also. This view of the subject has not 
escaped the notice of German pathologists. 

In the case above related the pains continued in one side for 
months, and were then suddenly transferred to the other, an occur- 
rence which is quite irreconcilable with the idea of their dependence 
on primary spinal disease. The well-marked ease the patient 
experienced when the gout appeared in the feet, and the perfect 
intermissions of pain which he frequently enjoyed during the ear- 
lier stages of the complaint, afford strong evidence that the pain^,. 
however violent and excruciating they might have been during 
the paroxysms, did not depend on an original affection of the spinal 
cord. Had the fall which this gentleman received, or any other 
injury, induced inflammation of the spinal cord, and subsequent 
degeneration of structure, the order and course of his symptoms 
would have been very different, and long intervals of comparative 
ease would not have intervened between the appearance of the first 
pains and the subsequent paralysis. 

When paraplegia originates in disease of the spinal cord itself, 
retention of urine, or irritabihty of the bladder, often announces the 
approach of the disease long before the loss of power in the limbs 
becomes evident : whereas, in all those cases in which the paralysis 
creeps from the extremities along the nerves towards the spinal 
marrow, the bladder is afiected only at a late period of the disease, 
as occurred in the case which I have just detailed. Finally, the 
remarkable siniilarity which exists, in various points, between this" 
case and that of the Welsh gentleman, who had never met with 
any accident or injury, and in whom a considerable degree of ra^ 
mollissement was observed, leaves no doubt that in both instances 
the disease commenced with gouty neuralgia, and inflammation of 
the nervous extremities and their sheaths, which gradually extended 
to the central portions of the nervous system, and ultimately 
involved the spinal cord. 

It is of great importance that practitioners should be aware of 



GOUT MAY AFFECT THE SPINAL MARROW. 367 

this termination, and know that in gouty habits the sad results 
ah'eady noticed may be produced, particularly as a knowledge of 
this fact may lead them to the timely adoption of preventive mea- 
sures. Having experienced the total inefficacy of colchicum, hydri- 
odate of potash, strychnine, and all the usual remedies, in relieving 
or removing this form of disease, I would be strongly inclined to 
recommend the early insertion of issues over the spine, with prompt 
and decided mercurialisation. Mr. CoUes has recommended the 
use of mercury in paraplegia, and cites some cases in support of the 
utility of the practice. It is to be regretted that he has not given 
any hints as to the mode of diagnosing the cases likely to be bene- 
fited by the mercurial treatment, from those in which mercury 
would be inadmissible. Hence his recommendation loses much of 
its value, and cannot serve as a guide to those who have to treat 
spinal diseases connected with paralytic symptoms. It appears, 
however, sufficiently plain, that mercury, employed at an early 
period of the disease, is most likely to prove serviceable where 
symptoms of paralysis arise from inflammatory affections of the 
nerves or their neurilema, or of the spinal cord and its sheath. 

So far at present on the subject of paralysis, as connected with 
the gouty diathesis. I hope to be able, at some future period, to , 
bring it again before you in a more complete and extended form.. 



LECTURE XIV. 

Gout may aflfect the spinal marrow — Combination of arthritic inflammation with broK- 
chitis — Effects of various remedies, particularly mercury — effects of this in chronie 
bronchitis — Dr. O'Beirae's plan of rapid mercurialisation in certain affections of the 
joints — Application of the same method to inflammation of the lungs of scrofulous 
character — Cases in illustration. 

In the two preceding lectures we proved that gout often attacks 
the nerves of the extremities in the first instance, and then pursues 
a retrograde course until it reaches the spinal marrow. It is an 
acknowledged character of gout that it wanders from one organ to 
another, and that it is very uncertain as to the periods and duration 
of its attacks, sometimes appearing to have ceased altogether, again 
only to return with redoubled violence. These characters of gout 
are strikingly displayed in the two cases I have related, where it 
finally seized on the spinal marrow ; and it is quite possible that 
what took place towards the fatal terminations of these cases, may 
in other gouty subjects occur at a much earlier period, and without 
the previous occupation by the disease of the nerves of the extre- 
mities: indeed, there is no reason why gout should not attack the 
spinal marrow and its investing membranes in the first instance, or 
in consequence of metastasis. That rheumatism, the disease most 



368 GRAVES'S CLINICAL LECTURES. 

closely allied to goui, may do so, has been proved by numerous 
examples, of which we owe some of the most striking to Dr. Cop- 
land and l)r. Prichard, for the result of whose researches on this 
subject I must refer you to the article Chorea, in Copland's Dic- 
tionary of Practical Medicine, where you will find that rheumatism 
not unfrequently produces both acute and chronic inflammation of 
the spinal membranes. These observations I make with the inten- 
tion of proving that my views concerning gouty affections of the 
spinal cord are borne out by analogy, and the experience of others 
with respect to rheumatism. 

The case of Coghlan, who has been for some time an inmate of 
our chronic ward, demands a few observations. He was admitted 
for an attack of arthritis on the 10th of December, and since that 
period has been subjected to various modes of treatment. You 
will recollect that on his admission he stated that he had been at- 
tacked several times with rheumatic inflammation of the joints. 
Like most persons of his class, he has suffered greatly from re- 
peated fits of illness, brought on by exposure to the same causes. 
One of the greatest misfortunes that can fall upon labouring men, 
is a severe attack of rheumatic fever accompanied by inflammatory 
affections of the joints; it not only renders them helpless and use- 
less for a considerable time, but also in some cases leaves them 
Clippies for life, and in addition, the nature of their employment 
constantly exposes them to relapses, which at length brings on in- 
curable affections of the joints : we have, moreover, in this young 
man's case, a combination not unfrequent in patients of this descrip- 
tion, namely, the effects of cold on the chest as well as on the joints, 
arthritis combined with inflammation of the bronchial mucous 
membrane. Now where the arthritic affection is very severe, and 
accompanied by high fever, the addition of bronchitis is a great 
aggravation. Every time the patient coughs he feels like one 
stretched upon the rack ; at every convulsive motion of the chest 
a severe pang is felt in every joint, and the ordinary rate of suffer- 
ing is increased to positive agony. A case of this kind is often 
hard to be managed, even when the disease is recent and the con- 
stitution sound ; but when you have to treat a severe attack in a 
person who has repeatedly laboured under the disease, and whose 
vigour has been consequently impaired, the difficulty is greatly in- 
creased. Here much attention is required on the part of the phy- 
sician. Where the combination is met with in a primary attack, I 
am generally disposed to regard both affections as of the same 
character, and not requiring any difference of treatment : I there- 
fore attack the arthritis and the bronchitis with the same remedies, 
that is to say, venesection, leeches to the affected joints and over 
the chest, and large doses of nitre and tartar emetic. These reme- 
dies, however, are only calculated for the acute stage of a primary 
attack, and where the patient's strength is unimpaired ; for when 
the disease is chronic, and debihty present, you cannot venture on 
the use of large doses of tartar emetic and nitre. In such cases 



MERCURY IN ARTHRITIC INFLAMMATION. 369 

much benefit is derived from the use of colchicum, particularly 
where the patient labours under more or less fever. The following 
is the form which I am in the habit of using, and from which I 
have occasionally derived much benefit. 

R MisturjE amygdalarum, 5viij. ; aceti colchici, 5ss. ; acetatis morphiae, 
gr. i. ; nitratis potasses, 5ss. ; sumat cochleare unum amplum omni vel 
secunda quaque hora. 

In Coghlan's case we tried this mixture with local applications 
to the joints and a blister to the chest, but found at the end of some 
days that there was no visible improvement in the patient. Now 
whenever a state of things of this kind occurs, no time should be 
lost ; for rely on it, that where colchicum does not afford relief in 
a short time, and in moderate doses, there is no use in giving it a 
further trial. You have here to contend with two affections of a 
very serious character — one capable of rendering your patient a 
cripple for life, the other threatening him with suffocation, from an 
extension of the inflammation into the minute bronchial tubes, an 
occurrence which is most commonly followed by dangerous con- 
gestion of the lung. Under such circumstances, the only treatment 
you can adopt with a hope of speedy relief and uhimate success, is 
to lay aside all other remedies, and trust almost exclusively to the 
use of mercury. In cases of this kind do not hesitate a moment, 
but mercurialise your patient at once, if his constitution be at all 
capable of bearing it. The treatment which was followed in the 
case under consideration was this ; — we gave the patient ten grains 
of hydrargyrum cum ereta, four times a dayr and with the view 
of relieving pain and the irritation of the bronchial mucous mem- 
brane, he took one drop of hydrocyanic acid and ten drops of tinc- 
ture of hyoscyamus, in half an ounce of almond emulsion, three 
times daily. 

Permit me here, to direct your attention for a moment to the in- 
fluence which mercury exercises over inflammatory affections of 
the joints, and over certain forms of inflammation of the mucous 
membrane. I, in common with most practitioners, look upon 
mercury as a most valuable remedy in the treatment of arthritic 
inflammation, and in certain forms of bronchitis, but I do not, 
however, advise its indiscriminate employment, or bid you mercu- 
rialise every case of bronchitis or arthritic inflammation ; you can 
cure very many cases of both without mercury, and you should 
only have recourse to it in emergencies, of which I shall speak 
afterwards, and where other remedies have failed. In treating 
bronchitis in general, I always try bleeding, leeching, blisters, and 
expectorants, before I have recourse to mercury. But where these 
fail, and the disease continues to wear a threatening aspect, you 
will^ often find that mercury will cure it in a very rapid and sur- 
prising manner. You had an example of this in a boy who was 
lately under treatment in the chronic ward. He had severe laryn- 
gitis with an extensive inflammation of the smaller bronchial tubes> 



370 GRAVES'S CLINICAL LECTURES. 

great dyspnoea, and considerable congestion of the lung, and you 
perceived that the moment he came under the influence of mercury 
all his symptoms were ameliorated. We gave the mercury ori- 
ginally for the laryngeal affection, but in giving it remarked that 
it would also cure the bronchitis, and such was actually the case. 
Observe, I do not give mercury in bronchitis as a general rule, — it 
is often unnecessary, and even sometimes wholly inadmissible. I 
will except from this that severe form of bronchitis, with conges- 
tion of the lung, in children after measles, which is best treated 
with calomel and ipecacuanha, as recommended by Dr. Cheyne. 
Many children were lost by severe attacks of this form of bronchi- 
tis, and by hooping-cough, accompanied by congestion of the lung, 
until Dr. Cheyne hit upon this simple but effectual plan of treat- 
ment. But in ordinary bronchitis of an acute character, and pro- 
ducing a tendency to congestion of the lung, I do not prescribe 
mercury until other means have failed. 

Now I believe every practical man is aware that mercury is one 
of the best remedies we can employ in many cases of acute and 
subacute bronchitis, but perhaps it is not generally known, that 
even in some cases of chronic bronchitis, that is to say, where the 
patient labours under chronic catarrh, with asthmatic symptoms, 
not only relief, but even a complete cure, is occasionally effected 
by the use of mercury. One of the first cases of this kind which 
struck me very forcibly, was under the care of Mr. Porter. The 
patient, who laboured under an attack of venereal laryngitis, had 
at the same time chronic bronchitis, with puriform expectoration 
and hectic, and as the use of the stethoscope was not then well 
understood, was supposed to be labouring under phthisis. From 
the violence of the laryngeal symptoms, however, Mr. Porter was 
obliged to give mercury, which not only arrested the laryngeal 
inflammation, but also cured the chronic bronchitis. I recollect, 
also the case of an elderly gentleman, treated by surgeon Mitchell, 
of Harcourt street, for an attack of very long-continued chronic 
bronchitis, with asthmatic symptoms, and who was subject to parox- 
ysms of coughing and violent dyspncea, which sometimes lasted for 
twelve hours together. Now this gentleman, after the failure of 
various remedies, took mercury, and with the most marked and 
permanent relief of his pulmonary symptoms. 1 was, it must be 
confessed, greatly surprised by the effects of mercurialisation in 
this case, and it was quite a novel thing to me to witness a chronic, 
la very chronic bronchitis, with copious expectoration and frequently 
recurring dyspnoea, aggravated so as to endanger life by the least 
cold ; it was, I say, novel to me to see a patient so aflfected, radi- 
cally cured by a mercurial salivation. Perhaps, however, nothing 
but the absolute refusal of the disease to yield to other remedies, 
could authorise the adoption of such a plan in the present state of 
our knowledge. 

This puts me in mind of a plan which I have adopted within 
the last year, in the treatment of certain diseases of the lungs, and 



SCROFULOUS INFLAMMATION OF THE LUNGS. 371 

on which I shall make a few observations, as it has not been spoken 
of by those who treat of the cure of pulmonary affections. I must 
here in justice confess that the idea of this plan of treatment is not 
solely mine, but was founded on an analogy derived from the re- 
searches and experiments of Dr. O'Beirne on scrofulous inflam- 
mation of the joints. An extensive experience and deep reflection 
first led Dr. O'Beirne to think that the acute stage of scrofulous in- 
flammation of the hip and knee joint might be made amenable to 
active and energetic treatment; in other words, that inflammatory 
afl^ections of the joints, which terminate in some of the worst and 
most fatal forms of disease, namely, morbus coxse and white 
swelling, might be checked in limine, and before the stage of 
hopeless ulceration was established. He therefore proceeded boldly 
and at once to try whether the disease might not be arrested in the 
commencement by rapid mercurialisation. 

Observe, this idea was completely new, it had never occurred to 
any other person, and was diametrically opposed to the theories of 
the day. The prevailing opinion on this subject was, that mercury 
was inadmissible, and could only produce mischief in persons of 
the scrofulous diathesis. Every one said, do not give mercury in 
such a case, it exacerbates scrofula, it even brings on scrofula in 
many instances where there had been no appearance of it pre- 
viously ; you can do no good v/ith it, and may do infinite mischief. 
Dr. O'Beirne, however, knew the difference between the proper 
and improper exhibition of mercury — between mercurialising the 
patient at once and fully, and then stopping, and the pernicious 
custom of giving long and irregular courses of mercury. He tried 
the remedy and succeeded, and the surgeons of Europe have justly 
appreciated the value and importance of his discovery. About two 
or three months before Dr. O'Beirne made his discovery public, I 
had translated, for the Dublin Medical Journal, a paper from a 
German author on the use of corrosive sublimate in baths, in the 
treatment of white swelling, and Dr. O'Beirne states that the publi- 
cation of this paper gave him courage at the time in pursuing a 
plan of treatment so much at variance with the opinions of the day. 
I published this paper, however, at the time merely as a curiosity; 
it was a novelty in practice of which I had no experience, and 
could not offer any explanation. This was reserved for Dr. O'B. 
He has shown in his memoir on the subject, that if you give mer- 
cury so as to aflfect the system rapidly, you will frequently succeed 
in curing the disease, particularly in the commencement. 

From this I was led by analogy to apply the same principle of 
treatment to incipient scrofulous inflammation of the lung, and I 
think I have often succeeded in checking at once this most formi- 
dable of human maladies. Phthisis, as every medical man knows, 
is capable of assuming a variety of forms, and presents at its origin 
much difference of aspect. In some, it rises slowly and insidiously, 
and the pulmonary symptoms are so quietly and gradually de- 
veloped that it would puzzle an intelligent practitioner, who had 



372 GRAVES'S CLINICAL LECTURES. 

the most ample opportunities of observing his patient from the be- 
ginning, to say at what particular period distinct evidence of danger 
had been noticed. The reason of this is because the tubercular 
affection of the lung is in such patients only of secondary import- 
ance, the disease which produced it having affected the whole sys- 
tem before the lung was contaminated. This happens in some, but 
in others an opposite train of phenomena is observed, and scrofu- 
lous inflammation commences in the lung before any general con- 
tamination of the system has taken place. It is in such cases, and 
such only, that mercury ought to be tried, and it will avail nothing 
except where the commencement of the scrofulous inflammation of 
the lung has arisen suddenly, and in consequence of the operation 
of some obvious cause, as catching cold or the occurrence of 
haemoptysis. I think that too much stress has been laid on the nf- 
fection of the lung by writers on phthisis. In some cases (I will 
admit even in the majority of instances) the disease commences in 
the lung, but in others it passes through many changes, and affects 
various organs before it attacks the lung. You will frequently see 
persons labouring under scrofulous irritation, accompanied by hectic, 
emaciation, loss of appetite, and excitement of pulse, long before 
you can find any trace of tubercular deposition in ^he lung. I am 
of opinion that many persons would die of phthisis even supposing 
they had no such organ as the lung. 

But let us suppose the case of a person of scrofulous habit who 
gets an attack of fever, with local inflammation, and that this in- 
flammation fastens on the lung. Take for instance the following 
case : a young man of robust and vigorous frame, but evidently of 
the scrofulous habit, who has laboured repeatedly under scrofulous 
ophthalmia in his infancy, and who has lost several members of 
his family by consumption, gets, we will suppose, a severe cold 
by overheating himself in walking into Dublin from the country 
on a damp evening. He is attacked next day with feverish symp- 
toms and severe catarrh, which soon becomes a formidable bron- 
chitis : but the young man, being of a vigorous habit and fond of 
company, continues to go out and expose himself to nighl air, until 
at length the catarrhal fever is changed into hectic, the oronchitis 
into organic disease of the lungs, tubercles become developed, 
and the disease passes into phthisis. Here, you perceive, a man 
gets an ordinary cold, which becomes a bronchitis ; he neglects 
this, and it passes into disease of the pulmonary tissue and tuber- 
cular ulceration. Now this is a very common course of diseased 
action in persons of a scrofulous habit, and I have in many such 
cases, been able to trace the fatal malady to a common cold exa- 
cerbated by neglect and bad treatment. You perceive that I do 
not use the ordinary nomenclature of writers on consumption ; I do 
not recognise the terms " tubercular inflammation" as connected 
with cases of this description ; indeed, I am inclined to think that 
the whole theory of inflammation being excited in the lung by the 
presence of tubercles is founded on erroneous views. I have repeat- 



SCROFULOUS INFLAMMATION OF THE LUNGS. 373 

edly found tubercles in the lungs of persons who died of other dis- 
eases, without any trace of inflammation around them, and I believe 
every pathologist will confirm this statement. From this and other 
reasons, I have been led to the conclusion that tubercles do not act 
in all cases as foreign bodies, and that the theory which attributes 
the origin of inflammation to their presence is wrong. In one of 
my published lectures, I have brought forward numerous argu- 
ments to show that we are in possession of a much truer and more 
intelligible pathological explanation of the fact in question.* You 
may have scrofulous inflammation of the bronchial mucous mem- 
brane, or you may have scrofulous inflammation of the lung, singly 
or combined, or, what is most frequently the case, you may have 
either or both accompanied by tubercular development. The deve- 
lopment of tubercles, however, in a case of scrot"ulous bronchitis 
or scrofulous pneumonia, is a coincidence, and not a cause ; and 
you may have either of those affections singly or combined, with- 
out any coexistent or preceding tubercular development. Most 
commonly scrofulous bronchitis and scrofulous pneumonia are con- 
joined ; the former seldom exists for any length of time without 
producing the latter, and the latter is usually attended by more or 
less derangement of the bronchial mucous membrane. 

But what I chiefly wish to direct your attention to on the present 
occasion (and it is a matter of the deepest importance) is, can we 
prevent the development of phthisis in a person of scrofulous habit 
who has caught cold, got a dangerous attack of bronchitis or 
pneumonia, and is threatened with hectic? I do not wish to enter 
here into any disquisition concerning the means to be adopted with 
the vievv of preventing tubercular deposition, or producing absorp- 
tion when tubercular matter has been deposited in the tissue of the 
lung. To prevent tubercular deposition you must ci^re the scro- 
fulous diathesis, if you can. But suppose you are called to a case 
of the kind I have already described, where a young man of scro- 
fulous diathesis gets a bad bronchitis or pneumonia, exacerbates it 
by neglect, and is threatened with hectic, what is the best plan you 
can pursue? My impression is that you should treat it as you 
would treat acute scrofulous inflammation of the knee or hip-joint ; 
in other words that you should mercurialise your patient rapidly 
and at once : do it suddenly and decidedly, but without pushing 
the mercury too far, and you will often arrest all the symptoms of 
the disease as it were by a charm. I could mention many cases 
which have been treated successfully in this way. I was very 
m.uch struck by the case of two eminent medical practitioners who 
came to Dublin within this last year to place themselves under the 
care of Dr. WilHam Stokes and myself. One was a person of 

* [There is no doubt of this, especially as to the scrofulous inflammation of the 
bronchial membrane. I have seen this extend much above the lower or proper 
bronchial portion, and affect particularly the nasal passages. This variety is 
most frequently accompanied by tubercles in the lungs, and usually yields 
readily to the use of iodine. — £d] 

32 



374 GBAVES'S CLESICAL LECTURES. 

scrofblons habit, who had caoght cold after taking mercmy, and 
neglectled it for three weeks. At the time we saw him he labomed 
onder severe and hai^assing coiogh, considerable fei^er and emaeia- 
tion, and was greatly alarmed aboot his condition. He had been 
seineral times leeched over the trachea by Dr. Stokes, hot this, 
ahhoagh an admirable remedy in many cases of bronchitis, failed 
in producing an amelioration of his symptoms, and from the per- 
s's r It i'^ fus fei^rishne^ emaciation, and har|i^ing coogh, 
5f : s f heasiODS were entertained that his disease would ter- 

:: : i 5. Having explained to our patient our views c: 

'. i -if : mDiession that mercury was the only remedy on 

V : : . 1 r wiih any hopes of success, we ordered him 

: ? "^omj continue the application of leeche? 
f : mercury. How as this gentleman hac 

: -" ' :'^ was consumptive, 

^T i : 5 jbfHjt to this mode 

>'i i r rat reluctance. 

I:: .: 5 ■ :t : : . i : ; l nearly disap- 

-:t: ^ _. _-. : 5 : " 5 : : ■ ; t : : . ^ : i : :' -.ercury tfce 



^^c>. 



pidaSy. Theothe: 

3S suddenly :■. 

5 c^me to Dui 



aep at e 



f the pulse, the hi 
: t rrepitus ar :' 5 
ieot the 



fectiy where mer: 



HYDRIODATE OF POTASH IN RHEUMATISM. 375 

it is a curious fact that about the time I had fallen upon this mode 
of treatment, it sun:2jested itself likewise to the minds of Dr. Stokes 
and Dr. Marsh, who can testify its utility: of course it will not 
succeed in all cases ; and I have seen it fail in two where I had 
confidently expected benefit. Notwithstanding this it is a most 
valuable addition to our resources in certain cases that would end 
in phthisis.* 

About a year ago I attended a young gentleman, apparently of 
robust constitution, who died of phthisis ushered in by a frequently 
recurring hemoptysis. Shortly after his death, Mr. William Grady, 
one of our most diligent and intelligent pupils, called on me to 
visit the elder brother of my former patient. He haa a constant 
hard, dry, and very distressing cough, which deprived him of 
sleep, and having continued many weeks had produced a most 
formidable degree of emaciation. Consumption was naturally 
dreaded. His pulse, however, was normal, and the stethoscope 
did not indicate any pulmonary lesion : still, as the case had re- 
fused to yield to all the ordinary remedies, including change of air, 
we felt very apprehensive as to the result. I confined him to bed, 
applied leeches over the trachea several times, and rapidly mer- 
curialised him, and with complete success. He has continued well 
ever since. 



LECTURE XV. 

Kydriodate of potash in rheumatism — Sarsaparilla and nitre in chronic cough — Re- 
marks on percussion — Clear sound with solidified lung — Fever with cerebral irrita- 
tion — Employment of tartar emetic and opium — Success of turpentine. 

I HAVE spoken on a former occasion of the utility of mercury in 
certain cases of rheumatic fever, where the inflammation of the 
joints will not yield to other means : I have now to add, that within 
the last year the hydriodate of potash has been found to be a most 
useful adjunct to mercury, and well calculated for following up 
and completing the beneficial efl?ects produced by that remedy. In 
fact, in treating arthritic or rheumatic fever, when I have reduced 
the violence of the fever and of the inflammatory affection of the 
joints by means of bleeding and leeching, followed by tartar emetic 
or nitre, or both combined, or wdien after the antiphlogistic treat- 
ment, both local and general, I have produced a marked alleviation 
of the patient's sufferings, either by the use of colchicum or by the 

* [We are far from objecting to this practice in general terms, but we reiterate 
the cautions of Dr. Graves. We have for a number of years been accustomed to 
resort to the mercurial treatment, pushed pretty rapidly too, in the management 
of tuberculous inflammations of ihe serous membranes, including pleura, perito- 
deum, and pia mater. — Ed."] 



376 GSATES^S CirniCAL JLECTCKES. 

use of mereniry coiniiiEied iddi opistte^^theia, I s^y^ we cam eanpfej 
tlie hyd riodate of pofiaali wiEh tlie greatest fio^lile adiTanta^ asit 
quickly cilsiapaies t^ rewiaJBEKn^ paia and swdsEig oi tbe jsm/is. 
and cofitriboSies powerfoHj to ht:mg %h^ diseasss to a spsdy 
iKifioiiv while at the sune time it ^r^atilj dioainidbes the 
a islapac I have csxperienced nmodb eooiBibrI and feel mi 
dence in the tseatinent of rheeenaSic ferer sioee I adoptsd this 
praditse; and it now nsv^x- haf^pens to me to oneeS: WKfih cas^ 
which, in ^ie of al! mj e^Mts, become cthioniCs and confine the 
unfcHtonale so^in^s to bed for months. Y&m hav^ observed, that 
in most caises ai acoiie ihessmatism afiectiiD^ the jdinfis^ no 
what mode of tmeatcifiait I ade^ in the eoGBmeneefiKent and 
the acme of ths disease, I geiBerallj compBele the cme with 
fajdiiodateof potadb^begpffliin^wich doses of ten giraiDS, wfaic 
€{OBcIdj ao^m^tted to twenty- or thirty girains three times a dsLj 
is generally giv^en in decoction of sarsafiarilla, to which some 
paration cf moqphia liffms an uselbl addition. 

lodofse and the hjdbiodate of polaah ^xert a ^ery ^w^^-': 
ence over sciofidoos inSammaSson, bnt their iBsSkBesace^ s. 5 
pgQved by lecent experience^ extends Kfeewiae to in^nnm-- 
neded with other slates oi the constilniion, aind they are : 
exhibited now with the best e^ets in cseitain vaffietses c : 
poeudo-syphifis, g;ooi, meicarial cachexy and iheomat 
power of iodine in moderatiof^ nBercurial sa£vation» and 
dberaticm tji the mooBh whsch fffeqaenily a cc om p ttnies it 
asserted by some and desned by others. Be this as it En ?. 
taini J is an exceiient adjmaM to ogr iBoal means Sar c 
the pain and inflammation which attend perio^bitic mSkc 
many ef the tronyesomesesp^ss eifsyphilisL Ima^obE^ 
that the hydriodate of potash has been found to prove a : 
able anxihairy in fhs treatment ai crfaioBic anasarca ac . 
and Mr. Swift jmsSmms ms^ that be has ensplby^ it with .. 
satis&€:tf»y resoi&s in the €iro|i^ of scadbtimfii^ paiticniaify iz 
drea d a wealk and t^aehecfiif^ habilL He oses the ^7:' : 
of poSa^ in combinatioB with fiquM* kai&, to which the t 

^ H^wpy^ j^ H^^ JK& lJTlli'li<wmiHnlilP #p nw wUUCflk 

I have been told Eltewise by some excelBent pirsrtr^ : : 

they have derived moch advaMa^firom theiodnr^ : 
niatic aSections cf the joiiilisv ater the ssxsMs stage 
My own expefience of die eSecta of tliis remedy h . : 
afiiow me to ex|Kess any &piiEmm on its merits. 

Havif^ spoken of mereorial saffivalion^ it occ : 
DKBt, that the remaiikahSe fact cf the cSiffio:' 
and very old persons most depend in mmsis : 
loped state of the parolid giiands in ths Ib'nueL^ 1 
and alrof}fned condiiion in the latfier. T^e i - 
with the iasalvatwDffl (oC the food k compara 
befiiire the, teeth appear m rnhmifr. or af*^*: . 
Taocedagc 



CLEAR SOUND WITH SOLIDIFIED LUNG. 377 

1 wish now to make a few observations on the use of decoction 
of sarsaparilla and nitric acid in certain cases of chronic cough. 
The utiHty of this combination has been long recognised in cachec- 
tic states of the system and affections of the skin, whether syphiHtic 
or mercurial ; and it has also proved itself very efficacious in va- 
rious species of sore throat, chronic pains, and other textural 
derangements of a slow and tedious character. The marked effects 
which the decoction of sarsaparilla and nitric acids produce in these 
diseases of the general habit, skin, and mucous membrane of the 
throat, led me to infer that the same combination might be employ- 
ed with advantage in cases of chronic cough, attended with redness 
and relaxation of the mucous membrane of the fauces, elongation 
of the uvula, and some degree of general debility. I have ob- 
served that such cases are almost invariably accompanied by more 
or less derangement of the digestive organs and an irritable state 
of the general system ; and from their analogy to other states of the 
constitution, in which nitric acid and sarsaparilla have proved ex- 
tremely beneficial, I was induced to give this combination a trial ; 
and I can now state that it has not disappointed my expectations. 
Decoction of sarsaparilla, given in doses of a pint daily, with a 
dram or more of nitric acid, has proved a most useful and valuable 
remedy in the treatment of cases of this description. It is scarcely 
necessary to observe, that in addition to the use of this remedy, 
change of air, moderate exercise and recreation, and a nutritious 
but not heating diet, are required. In some of these cases it will be 
also necessary to apply lotions of the nitrate of silver or sulphate of 
copper to the fauces and tonsils; and where the uvula is greatly 
relaxed, it will require to be frequently touched with the nitrate of 
silver, or even to be shortened by an operation. Guided by the 
sam.e principles, I have frequently exhibited decoction of sarsapa- 
rilla with nitric acid in cases of persons of a reduced and relaxed 
habit who are troubled with a slight but frequently recurring cough 
or hem, and the expectoration of a few bronchial sputa, occasion- 
ally mixed with blood, which appears to come, not from the lungs, 
but from the eroded mucous membrane at the top of the pharynx 
and larynx. In such cases I have observed that the cough and ex- 
pectoration took place chiefly in the morning after awaking, and 
in some had continued for weeks without any dyspnoea, pain in the 
chest, or fever. I may also remark, that the same combination may 
be often given with advantage to patients w^hose mouths have been 
recently made sore by mercury administered for the cure of bron- 
chitis or pneumonia, and will occasionally be found useful in re- 
moving the still lingering remnant of pulmonary disease, at a time 
when mercury could not be pushed farther with safety. 

Speaking of pulmonary affections leads me to notice a collateral 
subject of very great importance : I allude to percussion as a means 
of arriving at a true diagnosis in cases where solidification of the 
lung has taken place. It is generally believed, that in cases where 
the actual quantity of air in the lungs is morbidly increased of 

32* 



S38 d^l^lSS CaJSSCM. lJXmi!»S& 



aois^t^ ;l39 ^Ecay ^wsuieS^^ ^^sb^£^ ■mni. capdi^ csCmffiniODel a ^^ffii r a- 
^m. llfai^ iuMPevsr^ b nsit vk^ &dL It b ttsiae ikUL wise fesoB- 
laoB ^BSffliiGes ^maaSi^pe evaSBs^ ^ mcsieas^Si fmdsiGnaDnir ssEsiiBT 
"w® may he peifeflfly age gjaaft sBisSiiiffigBitfiiaa <£aatas; flnltSBZ 
B not Hbhib^isS %|w^ psscssi^m nn ot^sr^ casss ^Eff'Sikie ftasd 

^9 BHT ]^ BSBW aiQll flraCSf BSSSSpBES ffillStt BMfgByilP fpfW lll ITMI lUtt S 1M^ ^ 

derail aBafittcaaiom of tis hn^ iMid^iL CM l&oi I iave iiir- 



[1 infaasBa<9]3E£ttn!ffi isi* 



AmtMwsam^msm^ ¥^^ AA latta%, ait ^w P. BsnPs im^r: : 



le maaa^BBA to ssaodb an csi^ieafi. hf <aiii t 
ofaiB^wiikiBwiiMMiiiEtsdi^iBiKa^r. Hibwie 



OlB 




T«i«iilierai!Ib££t, 



FEVER WITH CEREBRAL IRRITATION. 379 

portion of the upper lobes impervious to the air, and may have 
solidified those lobes considerably, and yet the solidified portions 
may be so divided from each other by laminsB of healthy lung, and 
may be so covered by a stratum of vesicular tissue, that the general 
result of percussion is to elicit a clear sound over the whole of the 
parietes of the chest corresponding to the affected lobes. 

Since our last meeting, some cases of fever have occurred in our 
wards, which have presented too many points of interest to be 
passed over without any observation. A very curious case occur- 
red here, in a man named Toole, who was admitted on the 4th of 
January. This patient is a robust labouring man, about thirty 
years of age, and had been labouring under maculated fever for 
ten or eleven days before admission. Of his history previous to 
admission we could learn nothing; but when he came under our 
care he appeared very ill, and exliibited great depression of the 
vital energies, so that we found it necessary to encourage reaction 
by the application of heat to the surface of the body, frictions, 
warm fomentations, and the internal administration of wine and 
carbonate of ammonia. On the following night reaction became 
established; next day he became irritable and restless, and towards 
night was seized with dehrium. The nurse omitted to report his 
state to Mr. Parr, or the resident pupil ; he was thus left w^ithout 
any treatment until next morning. Now, this is a matter of much 
regret to me, and I think I cannot do a more essential service to 
those who are about to enter on the practice of their profession 
than to impress, as strongly as I can, the indispensable necessity 
of watching fever patients with the most anxious and unremitting 
diligence. In a case of bad fever, a single visit in the day will 
never suffice; two, and even three visits a-day will be required; 
and, when the patient is in a doubtful or dangerous condition, it 
will be often necessary to have a properly educated medical person 
in constant attendance, prepared to meet every emergency, and 
counteract or modify every unfavourable change. Fever will often 
run on for several days without any change calculated to arrest our 
attention, or call for the adoption of any new measures, and yet, in 
the space of six hours, an alteration may occur, of which the physi- 
cian should have early and full information. 

Well, this man remained without any treatment for several hours 
after delirium commenced. On the 6th, we ordered his head to be 
shaved and leeched, and prescribed tartar emetic, in doses of a 
quarter of a grain, every second hour. Next day we found him as 
bad as ever. The tartar emetic had failed in diminishing the cerebral 
symptoms, and his delirium had rather increased. We found also, 
on inquiry, that he had had no sleep for the last three nights. His 
pulse was weak and rapid, his eyes suffused, his restlessness and 
delirium such that he required a person to sit by him constantly, 
and prevent him from getting out of bed. Under these circum- 
stances, we ordered five drops of black drop to be added to each 
dose of the tartar emetic mixture, of which he took an ounce every 



380 GRAVES'S CLINICAL LECTUBES. 

third hour, that is, about a qaarfer of a grain of tartar emetic. 

He took four doses of this durina: the night : and next morning we 
found that the delirium and sleeplessness continued still unabated, 
and that the man was sinkinsr fa^t into a stale of stupor and insen- 
sibility. He neither answered questions, nor put out his tongue 
when deiired ; he had great subsultus, and was muttering to him- 
self with great volubility and rapidity of utterance. Indeed, his 
condition was such that I had no hope. Among other symptoms, 
I should mention that he had contraction of the pupils, a symptom 
of very unfavourable augury in fever. Having failed with tartar 
emetic alone, and afterwards with tartar emetic in combination 
with opium, I had nuw to seek for some other means of subduing 
cerebral irritation, and in this emergency had recourse to the use 
of turpentine — a remedy which I was inclined to adopt in prefer- 
ence to any other, as there was some fulness of the abdomen, and 
other symptoms indicating the existence of congestion of the intes- 
tinal mucous membrane. I therefore ordered two drams of the 
spirit of turpentine to be made up into a draught with a little oil 
and mucilage, and administered every second hour. Xow this is a 
point in the treatment of this man's case to which I would particu- 
larly direct your attention. 

I was guided here by a knowledge of the fact, that turpentine 
exercises a very remarkable influence over many forms of nervous 
irritation. I can refer for illustration to many affections of the ner- 
vous system characterised bv excitement, in which turpentine has 
been employed with the most signal benefit. Thus, we frequently 
find it a most valuable agent in the treatment of chorea, of epilepsy, 
and of the convulsive fits of children. We have frequently expe- 
rienced benefit from its use in the treatment of spasmodic afiections 
of the stomach and bowels; in hvsteria, tympanites, and the sub- 
sultus of tever, we often derive from it the most rapid and effectual 
relief. You recollect a case of typhus which was lately under 
treatment in our wards, and of which one of the most prominent 
symptoms was general and continued subsultus ; and you have all 
witnessed how much rehef the patient obtained from small doses of 
oil of turpentine. Hence I was led to cooclode that it might be 
employed with benefit in the latter stages of fever, where vascular 
excitement is greatly abated, and where the most prominent symp- 
toms are irritation of the nervous centres, with more or less con- 
gestion of the gastro-intestinal mucous membrane. In this case, 
however, I must confess I used it as a last resource, and did not 
anticipate the very striking results which followed so unexpectedly. 
After the second or third dose the patient had two or three full mo- 
tions from the bowels, and shortly afterwards fell into a sound and 
tranquil sleep, from which he awoke rational and refreshed. He 
is now wonderfully improved in every respect, and I have no doubt 
that his convalescence will go on favourably. 

There is one svmptom in this uian's case which is worthy of your 
attention, as connecied with the history of fever, although in other 



FEVER WITH CEREBRAL IRRITATION. 381 

respects it does not seem to possess much importance. I allude to 
the bullae which have appeared on the calves of his legs, on the 
inside of the ankles, and on the soles of the feet. This affection 
seems to belong to that class of eruptive diseases which are occa- 
sionally observed during the course of idiopathic fevers, particularly 
those whicli. have arisen from the introduction of an animal poison 
into the system. Thus we sometimes find an eruption of pustules, 
sometimes of vesicles, (as the miliary) ; occasionally we have bullae, 
and not unfrequently erysipelas. 

We have had another case of spotted or eruptive typhus, in a 
man named Henry Harpur, which has exhibited in the strongest 
manner the value of a combination of tartar emetic and opium in 
diminishing cerebral irritation, and bringing about a favourable 
change in cases characterised by symptoms of alarming and immi- 
nent danger. Those who have witnessed Harpur's case will con- 
fess that few cases could present a more unpromising appearance. 
He had violent delirium, requiring the restraint of the strait waist- 
coat, a furious aspect, suffusion of the eyes, constant raving and 
muttering, and perfect sleeplessness. His pulse was weak, thready, 
and rapid; his tongue and lips parched, fissured, and black; his 
breathing quick and irregular ; and his cerebral symptoms of such 
intensity as to leave little or no ground for hope. In addition, he 
had continued and general subsultus, and constant irregular mo- 
tions of the extremities. Now this man has been rescued from a 
state of the most imminent danger, and restored to convalescence, 
by the use of tartar emetic and opium. Those who saw the case 
two days since, and who have noticed the remarkably improved 
state of the patient to-day, will agree with me in saying, that so 
favourable a result could scarcely be expected. In this case the 
tartar emetic and opium were combined with musk and camphor. 
Where great subsultus tendinurn is present, in addition to the usual 
symptoms of cerebral excitement, I am in the habit of combining 
musk and cam»phor with tartar emetic, in the following form. 

B Mucilaginis gummi arabici, §ss. ; sympi papaveris albi, §j. ; antimonii 
tartarizati, gr. ij.; camphorae, gr. xv. ; moschi, 9ij. ; aquse fontis, 
givss. M. 

The camphor should be previously triturated with a few drops 
of alcohol, and the whole must be rubbed up in the form of an 
emulsion, of which a table-spoonful is to be taken every second 
hour, until copious discharges of fluid yellow faecal matter take 
place, — an occurrence always attended by much relief of the cere- 
bral and nervous symptoms, and which marks the period at which 
we ought to desist from the further use of tartar emetic. In the 
case which we are now considering, the medicine was administered 
in draughts, each of which contained half a grain of tartar emetic, 
ten grains of musk, five grains of camphor, and about ten drops of 
laudanum. After taking three such draughts the patient fell into a 
quiet sleep, which continued for several hours. He awoke quite 



382 GRAVES'S CLINICAL LECTURES. 

rational ; and since that period his improvement has been steady 
and progressive. I have not time to enter any further into the 
particulars of this case at present, and merely allude to it as one of 
those instances in which we have succeeded in allaying symptoms 
of cerebral excitement, where the state of the patient atforded very 
little grounds for any hope of a favourable termination. 

At my next lecture I purpose to lay before you, in detail, the 
history of the results which have attended the employment of tartar 
emetic and opium in fever, with some observations on its value as 
a therapeutic agent, and on the cases to which it is most peculiarly 
adapted. 



LECTURE XVI. 

On the efficacy of tartar emetic and opium in fever with much cerebral disturbance ; 

illustrated by cases. 

At my last lecture, I alluded to the use of tartar emetic in the 
treatment of the cerebral excitement and determination to the head, 
which are so frequently witnessed in the advanced stage of the 
present epidemic, typhus ; I shall now proceed to mention some of 
the beneficial effects derived from this plan of treatment, as illus- 
trated by cases which have recently occurred in my own practice, 
or in that of other members of the profession. 

Did I bring forward this plan of treatment as infallible, or if I 
boasted that it never failed, then indeed you might well doubt my 
judgment in recommending it to your notice, for infallible remedies 
never earn the sanction of experience ; but such is not the fact. 
This treatment we ourselves have seen will not always succeed ; 
nay, we must acknowledge that it has occasionally disappointed us 
even where we seemed justified in calculating upon success. But, 
gentlemen, we must recollect that every useful remedy is subject to 
the same charge, and that in the long list of therapeutic agents, 
there does not exist a single medicine which is fairly entitled to the 
appellation of a true and infallible specific. 

We have failed in several cases with tartar emetic, either alone 
or combined w-ilh opium and other medicines, and patients labour- 
ing under typhus have fallen victims to cerebral disease, although 
"we applied the remedy with all due diligence. Yet I think it but 
fair to observe, that most of the instances in which we failed were 
cases that had come under our notice at an advanced stage of fever, 
and where the cerebral symptoms had been wholly overlooked or 
improperly treated in the commencement of the disease. I may 
observe also, that cases of this description in which the cerebral 
symptoms have been permitted, before admission into hospital, to 
form themselves fully, are exceedingly difficult to manage, and ter- 



TARTAR EMETIC AND OPIUM IN FEVER. 383 

minate fatally at a much earlier period than the ordinary cases of 
typhus observed in private practice. 

Maculated typhus with determination to the head, when im- 
properly treated, terminates not unfrequently about the tenth, 
eleventh, or twelfth day ; sometimes it is protracted to the thirteenth 
or fourteenth, but most usually it ends fatally about the eleventh or 
twelfth. In neglected cases, the cerebral symptoms frequently as- 
sume a fearful violence on the seventh, eighth, or ninth day, and 
in such instances it must be expected that the best and most appro- 
priate plan of treatment will fail in rescuing the patient from im- 
pending dissolution. If, however, we can find out' a remedy, which, 
in many cases, apparently desperate, succeed in rescuing the 
patient from the jaws of death, we must be satisfied. A case of 
this description has occurred since our last meeting. It has excited 
the attention of all who witnessed it, as well from the violence of 
the symptoms, and the apparently hopeless state of the patient, as 
from the rapidity with which the exhibition of the remedies em- 
ployed was followed by a striking and decided alteration in the 
symptoms. Any one who saw him yesterday, would scarcely re- 
cognise him as the same individual to-day. 

This man, named Fogarty, was admitted about the seventh or 
eighth day of his fever, according to the account of his friends. Of 
course, in such cases, we cannot give implicit credence to those 
loose statements, for the lower class of persons in this country never 
calculate the time during which the patient remains out of bed 
struggling against the disease, — a period which, in a people inured 
to suffering and privation, frequently lasts three, four, or even six 
days. Well, this man aged five-and-twenty, and of rather robust 
constitution, was admitted on the 20th of December, being then 
about eight or nine days ill. Previous to admission he had taken 
purgative medicines, had his head shaved, and six leeches applied 
behind his ears, or to his temples, I forget which. Now all these 
measures, although perhaps insufficient, were extremely proper, 
and must have produced more or less benefit. When we examined 
him on the 21st, we found him in a state of high excitement, as 
manifested by continued mental wandering, incessant talking and 
raving, and frequent attempts to get out of bed. He had illusions 
of the senses of sight and hearing, consisting of terrific ocular 
spectra,* and alarming sounds, which threw him into a state of in- 
tense agitation ; his eye was red and watchful, and he never slept. 
Here then was a very threatening array of symptoms; — perfect in- 
somnia, ocular spectra, illusions of the sense of hearing, a fiery eye, 
and incessant mental wandering. To this was added, great de- 

'*' In a former lecture I mentioned that analogous symptoms result from in- 
creased or diminished sanguineous pressure on the brain ; the ocular spectra in 
Fogarty's case evidently depended on determination of blood to the head, but in 
the case of a lady, the wife of an eminent physician, a continued and varied 
succession of spectral illusions formed one of the chief symptoms, produced by 
exhausting hemorrhage after delivery. 



384 GRAVES'S CLINICAL LECTLTIES. 

rangement of the whole nervous system ; his body was agitated 
from head to foot by continual tremors, and he had violent and 
persistent subsultus: his respiration was interrupted, suspirious, and 
irregular, amounting at one time to forty in the minute, and a few 
minutes afterwards not exceeding twenty-five ; the acts of inspira- 
tion and expiration were extremely unequal, and occasionally ac- 
companied by blowing and whistling. In a former lecture, I made 
some observations on this form of respiration, which I termed 
cerebral, from having first observed it in persons subject to apo- 
plectic attacks, either before or during the paroxysms : it is fre- 
quently observed in bad cases of fever, and is a symptom of the 
greatest importance. He also lay constantly on his back ; his pulse 
120, soft, and very weak, so that the canal of the artery could be 
obliterated by v^ery slight pressure; his pupils were somewhat 
dilated ; tongue parched and brown in the centre, red at the edges 
and tip ; skin covered with maculas ; abdomen soft and full. Those 
who have witnessed the case will acknowledge that the picture I 
have drawn is not too highly coloured, but, on the contrary, falls 
far short of the reality, and no doubt you all expected that if we did 
not succeed at once in arresting the progress of his symptoms, the 
case must have proved rapidly fatal. Observe the position in which 
w^e were placed. In the commencement of the fever, certain ap- 
propriate but inadequate remedies had been employed, and, under a 
treatment proper but insufficient, the disease had progressed; it 
was an example of one of the worst forms of fever, characterised 
by intense cerebral excitement, and accompanied by total want of 
sleep, persistent delirium, and excessive disturbance of the nervous 
functions; all these symptoms had come on gradually, and arrived 
at their acme at a period when the low and debilitated stale of the 
patient precluded the use of depletive measures to such an extent 
as to exert any eflicient control over the most dangerous symptoms. 
The application of a few leeches would be extremely hazardous, 
and blistering would have been wholly useless and nugatory, for 
before a blister could rise the man would be dead. For these 
reasons, we concluded that the only remedy we could have re- 
course to with any prospect of success was tartar emetic. We 
therefore ordered a draught composed of two drachms of mint 
water, two of common water, and a quarter of a grain of tartar 
emetic, to be given every hour until it produced some decided effect 
on the constitution. You will recollect, here, that the scale was 
vibrating between life and death, that it was necessary that our 
plan of operation should be at once prompt and prudent, decisive 
and cautious. One of the pupils promised to stay by him the 
whole day and watch the effects of the remedy, and I determined 
to visit and examine him personally in the afternoon. In the 
course of four hours, he took four doses of the tartar emetic ; the 
first and second, in fact almost every dose vomited him, but not 
immediately. He retained each dose for a considerable time, and 
then threw it up. After the fourth dose, it began to act on his 



TARTAR EMETIC AND OPIUM IN FEVER. 335 

bowels, and then the medicine was suspended for some time, and a 
small quantity of porter administered. When I saw him at eight 
o^clock in the evening, he had been freely purged, and had dis- 
charged a considerable quantity of bilious yellow fluid from his 
bowels. He had also enjoyed about an hour's sleep ; his respiration 
was now more uniform and natural ; his raving greatly diminished; 
the subsultus and tremors were nearly gone, and the man appeared 
quite tranquil. I then ordered him a wine-glassful of porter, with 
two drops of black drop, to be repeated every second hour for three 
or four turns successively. I saw that the cerebral symptoms were 
evidently diminished, and that there was a tendency to returning 
tranquillity and repose, and I wished to follow up and assist the 
operations of nature. To-day this man is in a most favourable 
state. His skin is covered with a profuse warm perspiration, he 
has slept well, belly soft and natural, respiration slow and regular, 
and pulse diminished in frequency ; he is calm, rational, and com- 
posed, and I think 1 am not too sanguine in anticipating for him a 
speedy and certain recovery.* 

It is always an unpleasing and ungracious task for any individual 
to be obliged to come forward with proofs of the originality of his 
contributions to science; this task some have endeavoured to im- 
pose on me, and have sought to impugn both the originality and 
utility of my method of using tartar emetic and opium in typhus 
fever. Their arguments do not require any answer, and may 
be passed over in silence without any loss to you or prejudice to 
me, for certainly you could derive little profit from hearing the 
statements of my opponents, and I but slight credit from their re- 
futation ; suffice it then to say, that the prescriptions filed by the 
apothecaries of Dublin establish my claims, for you will search in 
vain among them for one, bearing a date prior to the publication of 
my papers on the use of tartar emetic and opium in the advanced 
stages of fever ^ and in which these medicines are prescribed in the 
way, or in anything like the way, recommended and practised 
by me. Since that date such prescriptions have daily become more 
numerous, and I am proud to bear testimony to the general 
liberality of the profession, for the greater number of my brethren 
have not merely tried my plan of treatment, but have acknowledged 
its utility, and have hastened to assure me that until my publications 
they had not seen it practised. But enough of this, let us not employ 
in general encomiums that time which may be more profitably dedi- 
cated to instructive details ; let us therefore again recur to facts. 

I have within the last fortnight received from Mr. Burke and Dr. 
Beauchamp the notes of an extremely interesting case of this de- 
scription. Mr. Burke is remarkable for his professional ability and 
his attention to his patients, and of Dr. Beauchamp I may state-, 
that his experience in fever is most extensive. The case is ex- 
tremely valuable as liaving been observed by Mr. Burke from the 

* He recovered rapidly and completely. 
33 



3BS 

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let iaer Have soooew^Bak cyd^hraiii amd li^ b^ob : tfce lalier 



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BBunageaiBfe;, qIhii^ previMdly ivcfj ^ol^ ^ 
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*< Dr. BcaBchaoBp asd I sbw ier bbH day aiioatt ttea o^ciodk ii 

aie fbreaooB, beii^ l&e fifteealli day caf Ier fevec Fievms to oor 
gcong into Ihe reoBi, tte Bnrae ^le bb a firi^fhlM |BCflflre of 
way siie speaft the B^hL She had becB peifedfy 

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pearedlKj - • aai ^ 




TARTAR EMETIC AND OPIUM IN FEVER. 387 

" The question now was, what were we to do ? we dared not ap- 
ply leeches, blisters would be doubtful, and the probability was that 
the patient would sink before they vesicated. There was no indi- 
cation for cold to the head, for the scalp was cool. Could we rely 
with safety on nervous medicines ? their very stimulus might hasten 
her to the tomb. The indication was to relieve ihe brain, and the 
question was, what medicine or combination of medicines would 
effect this safely 1 Under these circumstances, we happily thought 
of the treatment employed by you in somewhat similar cases. We 
immediately ordered a mixture containing three grains of tartar 
emetic, half a drachm of laudanum, and six ounces of water : of 
this a tablespoonful was administered every half hour, its effects 
being watched. We saw her again at one o'clock on the same day, 
and had the pleasure of finding her much improved. .She had 
taken three doses, and vomited twice. The expression of her 
countenance was much changed, it had lost its ferocity and wild- 
ness; her tongue was now moist, perspiration was beginning to ap- 
pear over the body, the pulse was soft and about 100, and the in- 
telligence, which had been absent for a considerable period, now 
reappeared. She was able to answer our questions, and expressed 
herself relieved. We ordered the medicine to be continued, giving 
a tablespoonful every hour. After taking two doses, she became 
perfectly quiet, fell into a profound and tranquil sleep, perspired 
copiously, and at our visit next morning at ten o'clock, we found 
her to our astonishment almost well. She looked cheerful and re- 
freshed, and spoke of the wonderful relief she obtained : her pulse 
was soft, and about 80; her skin natural, her tongue moist and 
clean. Dr. Beauchamp did not think it necessary to continue his 
visits, and all that remained for me was to conduct her by proper 
regimen from convalescence to perfect health. She is now quite 
well. 

" It is a source of gratification to me to have had the able assist- 
ance of Dr. Beauchamp on this occasion, and his presence during 
the eventful period adds much value to the case. Dr. B. remarked 
at the time when hope had fled, that he knew of no routine of 
practice which afforded a probability of being of service, so that we 
may fairly conclude, that but for your happy combination the pa- 
tient must have died." 

This is a very strong case, indeed there could scarcely be a more 
striking illustration of the value of tartar emetic and opium in the 
treatment of the cerebral symptoms of fever. The case too was 
one of great danger, the patient was of a nervous and weakly habit, 
and during the acme of the disease she had an attack of convul- 
sions. This is a very important and most formidable symptom in 
fever, particularly when superadded to others indicating a deranged 
state of the sensorium. We had a patient here, some time back, 
who had two convulsive paroxysms during the course of his fever, 
and you recollect that I told you that it was a symptom of unusual 
danger. Some time ago a gentleman, in discussing my cases, said 



388 GRAVES'S CLINICAL LECTTRES. 

that convulsions in fever were not so c-angeroos, but I had the 
satisfaction of quoting for him the aatbority of Hippocrates, to 
show that persons who have been attacked in this way verr seldom 
recovered. 

I shall conclude this lecture by detailing a very remarkable ease, 
which has been communicated to me very recently in a letter from 
Mr. Swift : — 

" J. Kinsela, a labourer, aged 23, of powerful make and robust 
constitution, was attacked with fever about the 14th or 15th of 
January. He complained during the ensuing week of intense 
headache, thirst, and debility, but had no medical treatment. On 
Saturday, the *21st, he was extremely ill and restless, and on Sun- 
day morning, while his clergyman and several of his friends were 
with him, he got out of bed in a state of furious delirium, seized a 
knife, and having cleared the room, rushed out into the street in 
his shirt, where he was secured by a policeman and some of his 
neighbours, and brought back to bed, having previously wounded 
several of his captors in the strugiile. He then fell into a state of 
coma, and when I saw him on the following Thursday, the 26th, 
he exhibited the following symptoms: — Decubitus on the back; 
eyes nearly closed ; lips red, dry, and chspped : forearms bent and 
agitated by apparently unconscious movements; convulsive twitches 
of the eyebrows and angles of the mouth; breathing irregular, 
heavy, and somewhat stertorous, (of that description which you 
have aptly termed cerebral) : pulse oppressed, unequal, weak, and 
about 110: great heat of scalp and face ; temperature of the body 
normal ; feet very cold. He had no pulmonary symptoms ; his 
belly was soft and apparently natural, but he gave indications of 
uneasiness when firm pressure was made over the situation of the 
stomjach and small intestine. He was raised up in bed, shaken 
roughly, and spoken to repeatedly, but gave no answer ; nor would 
he put out his tongue, or open his eyes, when requested. His 
tongue, as far as I could see it, appeared red. dry, crusted, and 
fissured ; and on raising his eyelids, I found the eyes greatly 
suffused, aud the pupils contracted nearly to the size of a pin's 
head. 

" His face, hands, and head, were bathed with warm vinegar and 
water, jars filled with hot water applied to his feet, and about two 
o'clock, P.M., he commenced taking tartar emetic in doses of a quar- 
ter of a grain every hour. It was combined with a small quantity 
of opium. 

" When I saw him again, about nine o'clock in the evening, be 
was wonderfully improved. He could be easily roused, answered 
questions distinctly, put out his tongue when desired, and appeared 
quite rational. He had taken about two grains of the tartar emetic, 
the effects of which appeared to be chieiiy confined to the circulat- 
ing system. His pulse was now equal and regular, the temperature 
of his body nearly uniform, and a slight degree of moisture could 
be felt on his skin, but he was neither vomited nor purged, A 



SUPERVENTION OF OTHER DISEASES. 389 

mixture, containing nitrate of potash and tincture of hyoscyamus, 
was substituted for the tartar emetic ; the fomentations of warm 
water and vinegar were continued, and he had a purgative enema 
with turpentine, which was followed by a full discharge from the 
bowels and copious diuresis. On Saturday, the 28th, he had an 
indistinct but favourable crisis ; his tongue became clean and soft, 
and his pulse diminished in frequency. On the following Tuesday, 
his pulse was 76, his tongue clean, eyes clear, pupils natural, appe- 
tite returning, so that 1 considered it unnecessary to continue my 
visits beyond the following day. His convalescence is now com- 
pletely established. 

" I have been particular in describing the cerebral symptoms in 
this case, as the patient's head was neither shaved, blistered, nor 
leeched. A portion of his hair was cut off with a scissors, and this 
was all that was done in addition to what I have mentioned. I at- 
tribute his recovery to the tartar emetic and opium, as under its 
use he recovered in a few hours from a state of stupor and coma, 
which otherwise must have speedily terminated in death, and I 
think this valuable remedy has additional claims to notice, if (as 
it would appear from Kinsela's case) it can be employed as a, sub- 
stitute for all the ordinary and expensive remedies used on such 
occasions, — remedies, which in dispensary practice, and among a 
pauper population like ours, it is often difficult, and sometimes im- 
possible, to procure." ^ 



LECTURE XVIL 

Supervention of other diseases on fever — Description of a peculiar form of low 
neuralgic inflammation, not identical with phlebitis — ■ Local affections with morbid 
poison producing cutaneous eruption — Vesicles of Colles. 

There is one fact connected with the history of fever, which 
should never be forgotten by those who are occupied in its treat- 
ment : I allude here to the occurrence of sudden accidents, or the 
supervention of other diseases, producing a material alteration in 
the circumstances of the case, and leading to new and more alarm- 
ing dangers. You should not divest yourselves of all further 
anxiety for the patient, or relax in your attentions, because the 
fever has exhibited a tendency to decline, and a favourable crisis 
has taken place : crisis may occur, and convalescence may be es- 
tablished, and yet the patient may relapse, or he may be struck 
down again by the unexpected incursion of a new and dangerous 
malady, or he may expire suddenly in the course of a few minutes. 
The functions of the brain and heart may suddenly give way, and 
death may take place unexpectedly and at once. Thus it not un- 
frequently happens that a patient during his convalescence falls into 

33* 



390 GRAVES'S CLINICAL LECTURES, 

a state of syncope, from remaiuiDg too long in the erect postore, 
and if assistance be not promptly afforded, life is speedily ex- 
tinguished. In the slate of debility "which follows acute and ex- 
hausting diseases, and where the patient is very liable to syncope, 
the most assiduous attention is required. During the epidemic of 
18*26, death took, place under such circumstances in five or six in- 
stances, and the convalescents lost their lives from incautiously 
silling up or walking about ine room too long, or attempting to 
reach the night-chair without assistance. There are many other 
causes capable of producing a sudden and alarming change in the 
state of convalescents from fever. One of the most obvious of 
these is error or excess in diet, which is apt to bring on a return of 
the fever in an aggravated form, accompanied by symptoms of 
gastro-enteric inflammation, and sometimes terminating fatally in 
forty-eight hours. 

To-day I propose to lay before you a sketch of a very important 
form of disease which attacks convalescents from fever, and runs a 
course of remarkable intensity and rapidity. I am not aware that 
this form of disease has been described by pathological writers ; the 
Dearest approach to a description of it is an account of the swelled 
leg which occurs after fever, given by a Glasgow physician. Dr. 
Stokes and I have given a description of a swelled leg afier fever, 
as observed during the epidemic of 1526, but the important and 
fatal form of the disease which I am about to describe, did not come 
under my notice until within a very recent period. 

Before the commencement of the present session, a fine young 
woman, aged 24, previously healthy and robust, was admitted into 
our fever ward. She was admitted on the 26th of September, 
having been at that time eight days ill, and labouring chiefly under 
gastric and cerebral symptoms. Her treatment consisted in the 
application of leeches to the epigastrium and head, cooling drinks, 
and blue pill combined with James's powder. Under the use of 
these and other appropriate remedies, the fever declined, and on the 
1st of October the cerebral and gastric symptoms had disappeared, 
and the patient complained merely of a slight degree of feverishness. 
On the 2d of October she was seized with rigors and horripilation, 
followed by intense pain of the left mamma, accompanied by numb- 
ness and loss of power of the corresponding arm. She was leeched 
with some relief, but passed a sleepless night, and next day an 
oblong patch of redness was seen extending upwards from the 
nipple ; the pain was still violent, and she could not bear the 
slightest touch on the afiected parts. The breast was leeched again, 
and fomented assiduously during the day. On the 4lh the erysipelas 
was spreading, and the pain was still agonising. She screan--ed 
out whenever it was touched, and could not bear even the weight 
of her dress or covering. On examining the breast, no enlarge- 
ment or hardness could be observed : there was no remarkable heat 
or tension, and with the exception of a slight erysipelatous redness, 
and pain rivalling that of tic douloureux in severity, there was 



SUPERVENTION OF OTHER DISEASES^ 391 

nothing to indicate the presence of disease. The left arm con- 
tinued numb and powerless. This state of things was accompanied 
by remarkable increase of fever, as manifested by foul tongue, ac- 
celerated pulse, and sleepless nights. She now began to complain 
of dull pain in the calf of the right leg, aggravated by pressure or 
motion, but not attended by any apparent increase of heat, swelling, 
or induration. On the 5th she is reported to have passed a sleepless 
night, although the watery extract of opium had been administered 
freely on the preceding day and evening ; the erysipelatous redness 
had extended nearly as high as the clavicle, and the affected parts 
had now begun to swell considerably. On the 6th she is stated to 
have had some sleep, and the erysipelas was extending, in some 
parts covered with vesicles. She again complained of cramps in 
the right leg, and on making an examination we found considerable 
tenderness on making deep pressure, but no external indication of 
disease. Her debility was increasing, accompanied by a tendency 
to looseness of bowels, for which she was ordered enamata of 
sulphate of quinine and laudanum. On the following night she 
was attacked with intense pain in the leg, accompanied by ex- 
quisite tenderness to the touch, but no redness, swelling, or increase 
of temperature. The erysipelatous affection of the breast had now 
become pale, and ceased to spread. The enemata were continued, 
the parts dressed with mercurial ointment and extract of belladonna, 
and wine freely allowed. She passed the night in great agony 
from the intense pain in the leg, and complained of frequently re- 
curring rigors followed by perspirations. She also stated that for 
the last two or three days she had experienced repeated attacks of 
tremor in the affected hmb ; one of these tremors attacked the limb 
on the night of the 8th, and continued for three or four hours, ter- 
minating in copious general perspiration. These increased on the 
following day, attended with increase of fever, thirst, and debility, 
and the pain in the leg continued with unabated violence. It is 
worthy of remark, that at this time there was no erysipelatous 
redness or discoloration of the affected limb, and scarcely any 
swelling. On the 9th, she is reported to have passed the night 
screaming and sleepless, she vomited three or four times, com- 
plained of intense pain in the abdomen, and had a violent rigor 
wliich continued from one o'clock to six in the morning, followed 
by profuse perspiration. The right leg continued exquisitely 
painful as before, became somewhat swollen, and its veins appeared 
more prominent than natural, but there was no discoloration of 
the integuments. Both arms were now painful on motion, and the 
left leg became painful and tender on pressure. Under this com- 
plication she sank rapidly, and died at three o'clock in the after- 
noon. 

On dissection, purulent matter was found under the integuments 
covering the left breast, but the gland itself appeared healthy. 
There was no vascularity or other traces of peritoneal inflamma- 
tion, and the abdominal viscera were healthy. The right leg was 



392 GRAVES'S CLINICAL LECTURES. 

infiltrated ; its veins were pervious and elastic, but their internal 
coat exhibited a rose-coloured tinge. 

Here, then, we have a very remarkable and formidable train of 
symptoms, arising without any obvious cause, running a rapid and 
fatal course, and exhibiting a character of singular intractability. 
From all that we had previously seen or heard, this young woman's 
constitution was robust and healthy, her fever had been treated 
successfully, and she appeared to be getting over it without any 
sinister accident, or any complication capable of disturbing her con- 
valescence ; yet at this period she is attacked with fever of a new 
type, accoAipanied by local affections of the breast and extremities, 
which run a rapidly fatal course, and exhibit phenomena of a new 
and extraordinary character. She is first attacked with erysipelas 
of the left mamma, accompanied by pain and loss of power of the 
corresponding arm ; then she gets exquisite pain of the right leg, 
and then of the left leg and right arm ; in fact the w^hole four 
extremities are more or less implicated. Now by what name 
should we designate this afiection, or what would be the most 
appropriate term to apply to it ? Was it phlebitis, or erysipelas, or 
phlegmasia dolens ? The affection of the mamma certainly resem- 
bled erysipelas, but differed from it in the agonising character of 
the pain, and I have already observed that in the legs or arms 
there was no appearance of redness or discoloration. That it was 
pure phlebitis 1 think we are not authorised in concluding, from the 
phenomena observed on dissection. There was no pus in the veins 
(an occurrence which might naturally be expected from the acute 
character of the disease,) no thickening or induration, the coats of 
the veins were elastic, and to all appearance healthy, wath the ex- 
ception of a rose-coloured tinge. Now considering the previous 
state of the woman's system, I do not think that we can conclude 
as to the existence of pure phlebitis on such slight grounds, or say 
that the whole group of symptoms which characterised the second- 
ary attack depended solely on inflammation of the veins. The dis- 
ease of which I speak simulated in many points phlegmasia dolens, 
but differed from it in the phenomena observed in the breast, as 
well as its more general difl^usion, and the absence of that pecuhar 
whiteness of the afl^ected limb which characterises the latter affec- 
tion. It appears to be a form of disease resulting from the genera- 
tion of a morbid poison in the system, and manifesting itself in 
diffuse subcutaneous inflammation of a low and cachectic nature, 
affecting primarily the skin and subcutaneous cellular tissue, and 
afterwards involving all the subjacent parts more or less according 
to their different susceptibilities. It was accompanied from the 
commencement with increased irritability of the muscular and cu- 
taneous nerves ; indeed, in the case just detailed, the nerves appear 
to be the parts primarily affected. Another remarkable circum- 
stance connected with this case is the loss of power, observed in the 
affected limbs. In all cases where a severe and painful affection of 
the nerves is present, you have more or less loss of power, but as 



PECULIAR FORM OF NEURALGIC INFLAMMATION. 393 

far as my observation has gone, there appears to be a difference in 
the derangement of muscular motion connected with painful affec- 
tions of large nervous trunks, and that which accompanies an af- 
fection of the terminating fibrils or nervous extremities. In the 
latter case the degree of paralysis is always more considerable; of 
this phlegmasia dolens affords a good illustration. In this disease 
the extremities of the nerves are chiefly affected, and the loss of 
power is always greater than when a large nervous trunk is affected, 
as for instance in sciatica. In the latter affection the pain is often 
extremely violent, but the motion of the limb is never so much im- 
peded as it is when the nervous extremities are the parts chiefly 
engaged. 

You perceive, then, that the affection which I have just described 
consists in the development of low, malignant, and irregular in- 
flammatory affections in various parts of the body, but particularly 
in the extremities, commencing probably in the subcutaneous cel- 
lular tissue, but subsequently extending to all the neighbouring 
parts, and exhibiting many of the characters of those inflammations 
which result from the presence of an animal poison in the system. 
A peculiar feature of this affection, also, is the intense neuralgic 
pain which accompanied it, and I think it might with some pro- 
priety be designated as neuralgic diffuse inflammation after fever. 
It is accompanied by a fever of a peculiar type, ushered in by 
rigors, and characterised by remarkable derangement of the di- 
gestive canal, debility, and sleeplessness. A point also which 
deserves notice in this case was, the recurrent rigors and perspira- 
tions, marking the occurrence of new and additional mischief, and 
indicating the malignant and intractable nature of the disease. 

One word as to the connection of this disease with phlebitis. 
Some pathologists are of opinion that phlegmasia dolens and swelled 
leg after fever are nothing more than modifications of phlebitis. I 
cannot, I must confess, agree with this opinion, nor am I prepared 
to admit that the symptoms in the foregoing case were referable to 
mere inflammation of the veins. I do not deny that the veins may 
be affected, but phlebitis is not the first link in the morbid chain, 
and is itself merely a consequence of the same unknown cause 
which determined the inflammation of other tissues. I beg leave 
to observe here, that the affection I have just described seems like 
others capable of existing in very difierent degrees. Thus, I have 
seen some instances in which there was no other symptom but 
severe pain of the extremities, generally about the calves of the legs, 
and which was relieved by warm fomentations and mild aperients. 
Again, I have seen, in addition to this symptom, swelling and 
tenderness of the legs, which, however, generally yielded to leech- 
ing and other appropriate means. Probably we are authorised 
from this and other facts in. concluding, that the disease is not 
always of a malignant and fatal character, and that there are at 
least certain forms of it amenable even to simple and ordinary 
treatment : you should, however, be always on your guard when 



394 GRATBB^ CXIMCAI. LECTUBES. 

patients recoveriDg from fever are attacked with pain, in the lower 
extremities particularlj, as this symptom not nnfinequeotlj oshers 
in a serioos and alarming disease. 

T T : r It case of this disease observed in onr wards, occurred 
c 5 : young woman, named Dillon, aged 23, and apparently of 
g: : 1 : r; jtion. She was admitted into the fever ward on the 
'2 ; ^ i i :^'. being at that time aboot seven or eight dajs ill. 
> i 55ion the Dsaal symptoms of fever, accompanied 

r 7 5 r ■ :' ? . d jspncea, costivene^ and loss of sleep. 

U .r. T s: :::!??, blisters, calomel, and other appropriate 
r ~ i r T r : rnarr symptoms declined, and she was 

: : 7 : : - . the i2lh. On the 18tli she had been 

u; :s : ng complained of rigors, and said 

5-i r T . >. ^ ::'. The painofthe Kmb coDtinued 

Li 7 r :; owing night, bot returned on 

: =-- . 7 : 7 7 i T- olence. She was leeched 

vr 7 : ; 7 :> reported to be extremely 

f; 7 i 7 7 i - r :*: :i!, bowels loose. She 

/. ; ::7: ? .. _ . . .7 7^ - ^s s::II exqaisitefy painful 

a.; 7 : : -.[ien. 6nehadtwi i 77 7: ?.gain applied with 

5: 7 .7 :n the 22d the Ic.; s/.^^.^er oecame similarly 

£.T7 7 ' : so tender as not to admit of the slightest 

~ 7 s 7 I : C : : - 575 was some diminution of pain in the leg 
1 7 5 5; was jerking and unequal ; her tongue 

: 7 7 i : 7 /. ^Qs ; and she complained of intense 

7 : . 7 ; i She passed a sleepless night, and 

Li 7 in in the left lower extremity. 

T . ; 35 . . e^ -/ _.. c:__c:bation of the febrile symptoms; 

s 7 . iotlv : her pulse became excessively feeble and 

n; 7 7: -A the 24th. 

' 'j . , 7 eritoneum, particularly that portion of it at- 

13. : z i ' ifietes, was found remaiiably vascular, 

I. 7 r - ■- intense over the hypogastric region. 

T i i 7 r : ymph or serum, but about half an ounce 

r : _ i r . - "is -.15 2; Tared in the cavity of the pelvis. The 
V : : 7 ? 7 i r.ealthy. The internal surface of the principal venous 
.: i 77 rgrd red, and there was a small quantity of coagu- 
1 7_ : : i . .iir cavities. On making an incision into the right 
ii. : r ^ : r :.f the internal saphena, the subcutaneous cel- 
: 7 7 : ?!ind infiltrated with sero-sangoineous fluid ; 

17 77 f 7 as here apparently natural, their cavity 

r 1:: r.i 7i r.jid blood, without any iymphy or pu- 

r . 7 :: nciixture. iMo distension or enlargement of the lymphatics 

H7 7 rave a ca?: 7?ponding in its main points with the 

f 5: i r h'ri^v in being complicated with 

T ; itis of the shoulder-joint. Its 

c: ^ . 1 ; : 77 :e ^-ne kind of intense neuralgic 

fi .:. ; . e sir.i; ;evt:: . .- 5::; .t ex.^.s.ve diffusion of local inflam- 



LOCAL AFFECTIONS WITH ERUPTION. 395 

mation, and the same unfavourable termination. The chief points 
of difference were, that in the latter case the disease attacked the 
synovial membrane of the shoulder-joint, and the serous membrane 
of the abdominal cavity. This, however, is by no means unusual. 
As to the synovitis, I have observed it in more than one instance 
after fever. I have witnessed a very remarkable instance of it in a 
man in this hospital who was attacked with swelled leg after fever. 
In addition to the affection of the leg, he had also synovitis of the 
knee-joint of so severe and intractable a character that he recovered 
with difficulty, with an anchylosed state of the joints. On the whole, 
the disease which we have been considering is one of great im- 
portance, and deserves particular attention. It is sometimes of a 
very unmanageable character, and baffles our best directed efforts. 
The treatment which appears best adapted for it consists in leech* 
ing, fomentations, and the application of mercurial ointment with 
extract of belladonna to the affected parts : these, combined with 
the internal use of quinine and opium, with occasional doses of 
calomel, seem to comprise the chief remedies on which we can place 
any reliance. 

Bearing some analogy to the foregoing, and requiring somewhat 
similar treatment, is another class of cases, in which, after some 
slight injury, and sometimes without any apparent cause, persons 
are attacked with local affections, attended by fever, remarkable 
sleeplessness, and an eruption of those pustules which were first 
described by Mr. Colles, and of which I have said something in a 
former lecture.* I shall read here for you the notes of an interest- 
ing case of this description which came recently under the notice 
of Mr. Trenor, a gentleman distinguished for the accuracy of his 
observation. 

A lady, aged about thirty, of dark hair and pale complexion, was 
visited by Mr. Trenor in October, being at that time three days ill. 
She had suffered some time previously from a cutaneous affection 
of the hands, which, from the appearance of the skin and the de- 
scription given by the patient, was supposed to be psoriasis. Three 
or four days before her illness she had pricked her finger with a 
needle, but did not pay any attention to it, as a similar accident 
had often happened before without any consequent inconvenience. 
On examination, three pustules or rather vesicles of different sizes 
were found on the inside of the finger and wrist, and there was an 
indistinct blush on the inside of the arm, which, however, the 
patient thought to be caused merely by the weight of the limb, as 
she lay on her side. The fore-arm was intensely painful, and the 
slightest touch excited extreme agony. The arm was also tender, 
and in the axilla was a small hard tumour, exquisitely tender to the 
touch, and from which the pain shot inwards over the anterior and 
upper part of the chest. The affected arm was powerless, and 
very painful on motion. Her pulse was 100 ; tongue white and 

* See Lecture viii. of this series. 



GRAVES'S CLIXICAL LECTURES. 

moist : bowels opened by medicine ; skin not differing much from 
the normal temperaiare: but she was extremely restless, and had 
not slept for the last two nights. She was ordered to take three 
erains of caiomel and two of the watery extract of opium at bed- 
time, and an aperient draught the following morning: the tumour 
in the axilla was carefully poulticed. On the following day the 
pain of the limb continued, but she had rested much better. The 
tomonr in the axilla was stationary. The calomel and opium were 
r^^eated in the same quantity night and morning, and she took a 
qmoiDe mixture every third hour. ISext day she appeared niuch 
easier, and under the same treatment, combined with occasional 
purgatives, she improved rapidly, and in the course of four or five 
days required no further treatment, except an opiate at bed-time, 
and the quinine mixture, which was continued for some time 
longer. The painful tumour of the axilla gradually disappeared of 
itself, for the local applications were given up at an early stage of 
the disease, being more inconvenient than serviceable» 

Here, you perceive, a train of severe constitutional and local 
symptoms arises from an apparently trivial injuni% and the patient 
is attacked with fever, sleeplessness, and exquisite pain of the atiected 
limb, accompanied by a slight blush of erysipelatous redness. 
There was also the same loss of muscular power which we observed 
in the cases of swelled leg after fever, showing that the extremities 
of the muscular as well as the cutaneous nerves were engaged, 
Now in this instance my friend took the same riew of the case as I 
did in a somewhat similar one which I am about to detail. He 
looked upon the irritative fever, the sleeplessness, the agonising 
pain, and the pustules, as symptoms not to be treated b}* bleeding, 
or leeches, or cold applications, or tartar emetic and nitre, but by 
tonics, opiates, and a mild nutritious diet. He gave calomel or 
blue pill, with full doses of opium and quinine, and ordered her to 
take chicken-broth and beef-tea. During the course of four days 
she took fifteen grain? of opium without any afiection of the head 
or derangement of the stomach, and nine grains of calomel and a 
drachm of blue pill in the same oeriod without any appearance of 
salivation. I have no doubt that in this instance the free use of 
opium tended not only to produce sleep and to relieve pain, but 
also to diminish the constitutional irritation on which the eruption 
of pustdes seemed to depend. 

The next case of this afiection deserving of notice is that of a 
French sailor boy admitted into Sir P. Dun's Hospital, labouring 
under a violent and dangerous form of fever, apparently typhous, 
but wanting the usual eruption of maculae. His pulse was but little 
accelerated at first, but he was very weak, restless and sleepless, 
and complained of exquisite pain in the side of the neck extending 
over the whole surface of the right ride from the angle of the jaw- 
to the tip of the shoulder. This region was very tender, and ex- 
hibited a diffused swelling and fulness with very shght redness, the 
latter only visible towards the centre. There was pain in the 



VESICLES OF COLLES. 397 

axilla, with incipient inflammation of one or two glands, and the 
right side of the chest, though neither red nor swollen, was very- 
painful on pressure. Immediately after detecting the existence of 
this diffuse inflammation, I remarked to the pupils that this was a 
case likely to favour the development of Colles's pustules, and 
accordingly I examined his skin and found two vesicles each as 
large as a shilling on the fingers of the right hand ; one of these 
vesicles was formed round a light superficial wound on the knuckle 
of the middle finger. Here it was not easy to determine whether 
the diff'use inflammation of the neck was a consequence of the 
wound on the knuckle, or whether the former arising spontaneously- 
had generated in the system a morbid poison which had reacted on 
the integuments around the wound, and formed a vesicle surround- 
ing it. I am inclined to adopt this latter opinion, for I have seen 
more than one similar case proving that where a poison is at work 
producing a tendency to cutaneous eruption, the existence of a 
small wound in the skin generally determines the morbid action 
towards that point of the surface, and causes, when any of Colles's 
vesicles are formed, the formation of one around the wounded spot. 
Thus in a grocer, ill of typhus, whom I lately visited along with 
Mr. Bourke, of Camden Street, one of these vesicles formed round 
a sore on his knuckle inflicted by a sharp scoop prior to the com- 
mencement of the spotted fever. Here the fever evidently en- 
gendered the poison, while the wound determined its action on the 
skin to a particular place : the same is observed in psoriasis, in 
venereal cachexy, and in small-pox. While the constitution labours 
under any of these diseases, injuries of the skin frequently call forth 
the specific cutaneous afl^ection in the injured part. 

But to return to the case of the French sailor. — At first the 
diflfuse inflammation of the neck was not accompanied by much 
fever, but in a few days suppurative fever set in, and a circum- 
scribed swelling was observable in the centre of the inflamed part. 
After a short time this was opened by Mr. Houston, and a large 
quantity of pus evacuated ; some improvement in his general 
heahh took place, and the peculiar distress produced by the diff'use 
inflammation in the neck, arm, and side, subsided ; the agonising 
tenderness had gone, and he seemed to be fast improving notwith- 
standing the profuse discharge of matter from the opened abscess, 
when suddenly he got acute hectic fever, rapid emaciation, and a 
sunken countenance, with cough and shortness of breath ; a rnoist 
crepitus was now discovered in the upper lobe of the right lung, 
just below the seat of the abscess. The case now assumed a most 
hopeless appearance, for in the exhausted state of our patient we 
had but slender hopes of his recovering from this pneumonia. The 
question occurred, what caused the pneumonia ? Did it arise from 
a communication between the abscess at the lower part of the neck 
and the upper lobe of the lung, or was it phthisis rapidly developed 
in a constitution run down by previous illness, or was it simple 
and self-existent pneumonia ? These are questions which it was 

34 



393 GEAVES'S CLINICAL LECTTIRES. 

lEOt very easy to determioe, and yet how important was the deter- 
minatioQ with reference to prognosis. If the pulmonary affection 
depended on an extension of the inflammation from the neck to the 
upper part of the lung, there was a chance of recovery, hut if it 
were phthisis, the boy was lost. I declared to the class my con- 
viction that it was phthisis, and for a few days the boy seemed 
hurrying to the grave, when suddenly the abscess in the neck dried 
up and became consoUdated, and at the very same time the pneu- 
monia in the lung just below the abscess disappeared as rapidly as 
it had arisen ! All fever subsided, and the boy, getting rid of his 
pectoral affection, was at once out of danger. I cannot explain 
ibs remarkable and unhoped-for termination of this affection, except 
OB the supposition, that the moist crepitus in the lung, and the pec- 
toral sjrraptoms, originated in a suppurative inflammation, suddenly 
extended from the lower part of the neck to the contiguous portion 
of the lung, and as suddenly ceasing when the abscess healed. I 
have dwelt on the particulars of this curious case, as I have neither 
seen nor read of anything similar. 

An old man from Bray, admitted into the clinical ward or Sir P. 
Dun's Hospital, exhibited extensive gangrenous erysipelas on the 
inside of the right knee and thigh, caused by a moxa, applied for 
the cure of pain in the knee. In a few days patches of diffuse 
inflammation, ending, some in sloughing, and some in suppuration, 
appeared on his hand, and other distant parts, and several of Colles's 
vesicles developed themselves on his trunk. Shortly after, another 
man, young and athletic, who had been bled for pneumonia, and 
in whom the wound in the vein had caused ill-conditioned diffuse 
inflammation at the bend of the arm, was admitted under my care. 
In him, too, Colles^s vesicles formed in various parts. To conclude, 
you may gather from the numerous examples we have witnessed, 
that these vesicles or pustu-Ies constitute a peculiar feature accom- 
panying many varieties of disease, which agree but in one circum- 
stance, the formation of a cutaneous eruption, caused by the ope- 
ration of a morbid poison, generated in some cases in the system 
itself, in others introduced from extraneous sources. iVmong the 
most frequent causes that give rise to the evolution of this poison 
in the system, is diffuse inflammation, no matter how produced — 
whether by a bruise, a burn, a punctured wound, a bed-sore, or the 
poison of glanders. In fine, you may remark that the cutaneous 
affection thus caused bears some analogy to exanthematous diseases 
of a malignant character, and marks a state of the system requiring 
wine, opium, and quinine. In most instances the eruption is either 
pustular or vesicular, but in some it assumes the appearance of 
small patches of diffuse inflammation, or of ill-conditioned furuncles. 



DROPSY FOLLOWING SCARLATINA. 399 



LECTURE XVIII. 

Dropsy following scarlatina ; utility of bleeding — Albuminous urine not necessarily 
the result of diseased kidney — Pulmonary aftection after fever; smilax aspera — 
Phlegmasia dolens not dependent on phlebitis ; treatment — Case of metritis — 
Melasna; various kinds of black discharge from the bowels ; green stools not always 
a sign of deranged liver. 

The case of William Young, who was admitted on Wednesday- 
last, has some claims to your attention, and demands a few obser- 
vations on my part. This boy, w^ho is about twelve years of age, 
had an attack of scarlatina some time ago, and had been dropsical 
for a week or ten days at the period of his admission. He was 
somewhat feverish, had thirst, heat of skin, and slight headache, 
cough and difficulty of breathing, and on making an examination 
with the stethoscope, we detected numerous bronchial rales ; his 
lower extremities were anasarcous, and he had some effusion into 
the peritoneal sac. We could not ascertain exactly the time when 
this train of symptoms commenced, but it is very probable that it 
was a week or ten days after the disappearance of scarlatina. 
When patients who have been recently labouring under an attack 
of scarlatina take cold, the anasarcous symptoms appear in a very 
short time after the attack ; but even where they are not exposed 
to cold, the dropsy appears generally about ten days or a fortnight 
after scarlatina, and is very often accompanied by some pectoral 
affection. The disease sets in with febrile exacerbations more or 
less niarked; anasarca of the extremities is next noticed, and at the 
same time the patient has slight cough and difHculty of breathing, 
which generally proceeds from congestion of the bronchial mucous 
membrane, but may be the result (though less frequent) of pleuritis 
or pneumonia. 

If called to a case of this kind in the commencement, and where 
the patient is not greatly exhausted by previous disease, the treat- 
ment is exceedingly simple. By opening a vein in the arm, and 
abstracting a quantity of blood proportioned to the age and strength 
of the patient, you remove the inflammatory state of the constitution, 
and arrest at once the anasarcous and pectoral symptoms. It may 
occasionally happen that active measures of this kind cannot be 
taken in consequence of the great debility of the patient from pre- 
vious disease; but generally speaking, cases of anasarca after scar- 
latina bear antiphlogistic treatment well. It is not after cases of 
violent scarlatina, or where the patient's life has been in imminent 
danger, that the supervention of dropsy is most commonly observed; 
the majority of dropsical cases of this kind are met with in patients 
who have had the disease mildly, and without any remarkable in- 
tensity either of the local or general symptoms. Hence, venesection 
is borne well, and its performance attended by the most decided 



400 GRAVES'S CLINICAL LECTURES. 

good effects, particularly where the dropsy is complicated with 
pleuritis or pneumonia. 

In the case before us, however, being uncertain as to the exact 
duration of the disease, and finding several symptoms present indi- 
cative of weakness, we were obliged to proceed with more caution. 
The boy had been ill a week, and appeared to be under the influ- 
ence of digitalis administered before his admission, for his pulse 
was intermittent and wavering. Under these circumstances I de- 
termined to limit the antiphlogistic measures to the application of a 
few leeches over the abdomen. I did this with less hesitation, as 
an accurate examination of the chest showed that there was neither 
pleuritis nor pneumonia present. The internal remedies were cal- 
culated to increase the secretion from the kidneys. The boy's 
urine w'as remarkably albuminous, and of the specific gravity of 
1027. This is a point worthy of remark. In many cases of dropsy 
after scarlatina, the urine is albuminous. Now, almost every case 
of this kind will get well, and as convalescence progresses, you 
will observe that the urine ceases to be albuminous. These facts, 
of the truth of which I can speak with the fullest confidence, are 
quite sufficient to show that those persons are wrong who assert 
that albuminous urine is the result of organic disease of the kidneys. 
Albuminous urine is here, as Dr. Blackall observes, merely an indi- 
cation of a peculiar inflammatory condition of the whole system, 
and not of degeneration of the kidneys. I may observe, however, 
that this is not always the case; for I could point out examples 
where albuminous urine is connected with an apparently opposite 
condition of the system : in fact, a condition demanding the use of 
a generous diet and tonics. Hence, there must be great diversity in 
the treatment of dropsy with albuminous urine. Where it occurs 
after scarlatina, and is accompanied by febrile symptoms, it is best 
treated by the lancet, nitre, purgatives, and digitalis ; but where it 
occurs in chronic cases, without any remarkable excitement of the 
vascular system, without organic disease, and wath more or less 
debility, it requires to be treated with tonics, generous diet, and 
full doses of opium. In the present case I only applied a few 
leeches to the belly, and kept the bowels gently open for the first 
few days, being determined to wait until the pulse became regular 
before I ventured on any decided plan of treatment. I then ordered 
mercurial frictions to the abdomen and axillae, and gave mercury 
internally combined with small quantities of digitalis. He also got 
a draught twice a day composed of carbonate soda, tincture of squill, 
and syrup of orange peel. These remedies we shall continue for 
some time, carefully watching their effects. 

From the state of weakness this boy was in at the period of his 
admission, and the length of time the disease has lasted, I have not 
thought it advisable to bleed him.* When cases of this kind be- 

* This case went on unfavourably, and the boy died, after lingering- several 
weeks, in a state of extreme dropsical swelling and great suffering, distension, 
and dyspnoea. As his urine continued highly albunainous throughout, we were 



PULMONARY AFFECTION AFTER FEVER. 401 

come chronic, they are very difRcult of cure, and require very deli- 
cate management. You will frequently have to run through the 
whole list of remedies employed on such occasions before you can 
hit on one that proves successful. I recollect a case of this kind, 
in which the anasarca was extreme, and the boy's legs were enor- 
mously swollen ; the dropsy was accompanied by scanty secretion 
of urine, but without any distinct febrile excitement. After having 
used every remedy I could think of, for nearly three months, with- 
out any benefit, I resolved to try the effects of cold effusion, from 
which I had experienced much advantage some time previously in 
another case. I ordered a large vessel filled with pump water, in 
which a quantity of salt had been dissolved, to be poured over him 
twice a day, for the space of two or three minutes each time, im- 
mediately after which the boy was wiped perfectly dry and put to 
bed. The good effects of this measure became soon evident ; a 
copious discharge of urine took place, the swelling of the limbs 
subsided, and in six or seven days the child was able to run about 
as usual. 

Allow me to refer briefly to the case of Garret Kane, of which 
I have spoken on a former occasion. You are aware that this man, 
after an attack of fever, had symptoms of , tubercular deposition in 
the upper part of the left lung. From the circumstances, however, 
of the other lung being perfectly sound, there being no fever or 
vascular excitement present, and the small extent of the disease, as 
well as the patient's youth and the season of the year, we were led 
to hope that we might be able to arrest the morbid process going 
on in the lung. After freely leeching the chest, we inserted a seton 
under the clavicle, and gave such remedies as are calculated to 
relieve cough and pulmonary irritation. We first gave the cyanu- 
ret of potash, from which he derived some benefit, but for the last 
weak we have been giving a dram of the syrup of smilax aspera 
in an ounce of water, three times a day. This remedy, which has 
been lately introduced into practice, possesses many of the properties 
of sarsaparilla, in addition to which it appears to contain a small 
portion of prussic acid, as denoted by its smell, which closely re- 
sembles that of laurel water. It has been very highly spoken of, 
and I believe it to be an excellent remedy, but, as in all cases of 

excessively carious to learn what was the condition of his kidneys. The post- 
mortem examination was made a few hours after death, and the kidneys were 
found in every respect healthy; their size, shape, consistence, and colour were 
perfectly normal. So striking an exception to the general rule ought to shake 
the confidence of those who assert that albuminous urine results from Bright's 
kidney. The long-continued presence of albuminous urine, in a case where no 
such state of kidney existed, forms conclusive evidence that this state of urine 
is not necessarily the result of that renal degeneration to which it is referred by 
Dr. Bright; the occurrence of one positive exception is sufficient to disprove 
such a conclusion, even though supported by a thousand cases, and, consequently, 
when albuminous urine in chronic dropsy is found to occur along with Bright's 
kidney, I consider this particular state of urine and of kidney as depending 
upon different causes, which often co-exist in chronic dropsy, and consequently 
I regard albuminous urine as a sign of Bright's kidney, but not as its result. 

34* 



402 GRAVES'S CLINICAL LECTURES. 

new medicines, I fear its powers are somewhat overrated. That 
it will fail in some cases I am quite convinced, for in the case of a 
gentleman in Mount street, whose symptoms were chronic bron- 
chitis, with violent and harassing cough, and who had been blooded, 
cupped, and used various internal remedies, I gave it a fair trial, 
and found that it did not produce any allevation whatever of his 
symptoms. 

Let me now direct your attention to the case of Rebecca Howard, 
who came into hospital on the first of this month, eight days after 
her accouchement, with painful swelling of both low^er extremities. 
From the history of her case it appears, that three or four days 
after her confinement she got severe pain about the heel and inner 
ankle, accompanied by swelling, which commenced about the same 
situation, and extended rapidly up the thigh as far as the groin. A 
similar swelling appeared likewise in the other limb, but instead of 
commencing below% it appeared first in the upper third of the thigh 
and afterwards spread downwards, attended with violent pain, ap- 
parently in the course of the great sciatic nerve. Along the course 
of the veins a number of hard cords, extremely tender to the touch, 
could be distinctly felt ; the lymphatics, though somewhat tender 
also, did not seem to be so much engaged, and there was no inflam- 
mation of the glands of the groin. 

Here we had a case of phlegmasia dolens, or, in other words, 
painful inflammatory oedema of the lower extremities, involving the 
skin, subcutaneous cellular tissue, veins,, and lymphatics, more or 
less distinctly. I have before stated to you my opinion, that this 
affection does not necessarily depend on phlebitis; on the contrary, 
I think that in the majority of cases the disease commences in the 
subcutaneous cellular tissue, and afterwards extends to the veins 
and lymphatics. Observe the course of the inflammation in both 
limbs. In one it commences in the vicinity of the inner ankle and 
extends up the thigh ; in the other, it is first observed in the upper 
part of the thigh, and spreads downwards. Now, where oedema is 
the consequence of phlebitis, or where it is artificially produced by 
tying or compressing one of the large venous trunks, it is always 
first observed in the lower part of the hmb. You perceive, then, 
that those who explain the occurrence of phlegmasia dolens by re- 
ferring it exclusively to phlebitis, are not able to account for it as 
com.mencing in the thigh and spreading downwards. But how 
much easier is the explanation, if we look upon it as a peculiar in- 
flammation of the subcutaneous cellular membrane of the limb, 
involving in its progress, to a greater or lesser extent, the veins 
andlymiphatics, and sometimes extending to the joints. From this 
view of the pathology of phlegmasia dolens, you can understand 
why the upper part of the thigh may become primarily aflfected, and 
that effusion may take place above before it occurs below. 

So far with respect to the pathology of the disease : now with 
regard to treatment. In attempting to remove this inflammation, 
we were obliged to keep clear of any measures calculated to in- 



PHLEGMASIA DOLENS. 403 

crease constitutional debility. The woman, though young, was of 
a delicate constitution; and there is this peculiar difficulty in the 
treatnnent of diseases after parturition, that they occur at a time 
when the patient has been more or less debilitated by the efforts of 
labour and its consequences. Our object, therefore, was to reduce 
the local inflammation, at the same time that we endeavoured to 
support the woman's strength by a light and nutritious, but not 
heating diet. We commenced with the application of leeches, to 
the number of ten, along the inside of each limb ; these we repeated 
to the same amount on the following day. In the application of 
leeches in cases of this kind, you must be guided by the circum- 
stances of pain, tension, and swelling; these are sometimes greater 
in one portion of the limb than in another, most frequently in the 
course of the veins; but you should always take care to have them 
applied over those spots in which the inflammatory process seems to 
exist in the greatest intensity. Our next step was to open her bowels 
by means of purgative injections, to be repeated as occasion required. 
In addition to this, I directed the limb to be gently rubbed with an 
ointment composed of one ounce of mercurial ointment, two ounces 
of lard, and three drams of extract of belladonna. I have already 
dwelt so often on the local, antiphlogistic, and narcotic effects of 
this composition, that it is unnecessary for me to say anything of it 
at present. 

With respect to internal remedies, I ordered her to take five 
grains of Plummer's pill every night and morning ; but as this pro- 
duced griping and a tendency to diarrhoea, we were obliged to 
change it for hydrarg. c. creta, with Dover's powder. On the 24th 
(the flfth day of her treatment) her mouth became aflTected, and the 
pain along the sciatic nerve, as well as the general soreness of both 
extremities, decreased. I forgot to observe, that from the com- 
mencement we had given opiates freely ; indeed, this was one of 
the principal parts of our treatment. She first took the liquor of 
the muriate of morphia, in doses of twenty drops, three times a day : 
this we exchanged for opiate injections, when her bowels became 
irritable under the use of Plummer's pill. On the 24th there was 
a considerable improvement in her symptoms, as I have already 
stated ; but she was very weak ; there was still considerable sore- 
ness of the extremities, and she complained of pain and tenderness 
in the' right groin, showing that the lymphatics as well as the veins 
were engaged. I ordered the opiate enema to be repeated, and 
allowed her the free use of chicken-broth, rice, and a small quantity 
of wine. On the 25th she was directed to take a pill containing 
half a grain of opium every third hour. Next day the report states 
that she finds herself much better, that her bowels are quite natural, 
that she feels no pain in the lower extremities, except when pressed 
or moved, and that she had regained the power of her limbs. Two 
days afterwards she was able to stand, and at present she is so far 
recovered that I intend to dismiss her to-morrow. 

The treatment of cases of this description involves some very 



404 GRAVES'S CLINICAL LECTURES. 

curious and important considerations. With the exception of leech- 
ing, the treatment which we employed in this case cannot be called 
antiphlogistic ; for throughout the whole course of the disease "we 
gave opium freely, allowed her nutritious diet, and after the first 
four or five days the use of wine. This shows that, in diseases 
called inflammatory, no general rule of treatment can be laid down, 
and that our practice must vary in the most remarkable manner, 
according to circumstances. Had I treated this inflammation by 
leeching, low diet, purgatives, and antimonials, it is very probable 
she would have sunk. But while we were endeavouring to subdue 
local inflammation by leeching and mercurial ointment, we sup- 
ported the constitution by a proper diet, nourishing but not heating, 
and afterwards by the use of wine. At the same time we gave opium 
in free and repealed doses, with the view of diminishing pain and 
irritation, and procuring sleep — a most important matter in the 
treatment of all acute afl^ections combined with irritability. We 
also gave mercury internally, because it has been found extremely 
valuable in such cases, w'hen given rather as an alterative than 
with the view of rapidly and violently aflecting the system. Under 
this plan of treatment her convalescence has been very rapid. It 
is a plan abundantly simple, but one which I can recommend to 
you with confidence. 

With respect to the after-treatment of this case, I have merely 
to observe, that as soon as the hyper-sensibility of the limbs became 
diminished, I ordered them to be rubbed diligently twice a day 
with warm olive oil. How this acts I cannot distinctly say ; but it 
appears to diminish tension, to promote absorption, and to increase 
the pliability of the limbs. Latterly, we have given up this, and 
had recourse to dry friction and bandages. At present she is taking, 
three times a day, a niild tonic draught, composed of tincture of 
orange peel, half a dram ; tincture of hops, twenty minims ; carbo- 
nate of soda, five grains ; water, an ounce. 

Let me next turn your attention to the case of Esther Green, 
who was also admitted here shortly after her confinement. I may 
observe that our proximity to the Lying-in Hospital in Cumberland 
street, under the care of Dr. Beatiy, assisted by Dr. Montgomery, 
gives us an opportunity of witnessing many cases of female com- 
plaints. This woman was delivered on the 5th of March, and 
dismissed about six days afterwards, apparently well. On the 
29th, after having previously taken cold, she got symptoms of fever, 
accompanied by pain of the belly, chiefly afi^ecting her in the hypo- 
gastric and right iliac regions. When she came in on the 31st, 
there was very little fever present, her pulse was slow and regular, 
and her skin cool ; but she was pale and anxious, had general ten- 
derness of belly, with griping diarrhoea and nausea, and complained 
still of considerable tenderness on pressure over the region of the 
uterus. Having consulted with Dr. Montgomery, we ascertained 
that the uterus was enlarged and painful. The case, then, was one 
of metritis, but not of a very acute character, and which had pro- 



PECULIARITIES IN THE ALVINE DISCHARGES. 405 

duced by sympathy a disturbance in the functions of the stomach 
and intestinal canal. 

Eight leeches were applied over the region of the uterus, to be 
repeated daily, until the pain and tenderness were relieved. We 
next had recourse to the use of mercury ; but as her bowels were 
in an irritable state, we prescribed the mildest of the mercurial pre- 
parations, hydrarg. c. creta, and to this we added Dover's powder. 
Two scruples of the former to ten grains of the latter were divided 
into twelve pills, two to be taken every fourth hour. This combi- 
nation is extremely valuable in many cases of inflammation of the 
viscera of the abdomen, particularly when accompanied by irritation 
of the intestinal mucous membrane, as manifested by griping and 
diarrhoea. After two dai^s there was a slight fetor of breath apparent, 
and we gave the pills twice a day instead of every fourth hour, as 
our object was to afl^ect the system gently, and not bring on profuse 
salivation. These remedies, with the use of blisters over the region 
of the uterus, will be quite sufficient to remove the disease. The 
metritis is not very acute, nor has it anything of a specific character; 
there is no puriform or other morbid discharge from the vagina, 
and the patient is a young woman of goo'^d constitution.* 

A patient who is at present in the chronic ward presents some 
circumstances worthy of observation, as connected with peculiar 
varieties in the alvine discharge. She has been labouring for some 
time under melasna, and, as you have observed, passes daily a large 
quantity of dejections from her bowels, as black as ink. The colour 
of matters discharged from the bowels is subject to very great va- 
riety. In some cases they are clay-coloured or whitish, somewhat 
like barm ; and I have seen them still whiter, and approaching the 
hue of milk. It is in cases of the latter kind, where the discharges 
are of a milky appearance, that persons have been said to pass chyle, 
and their emaciation has been attributed to a deficiency of nutri- 
ment depending on this cause. This, however, is not the fact; in 
some cases of chronic dysentery and diarrhoea, a fluid whitish dis- 
charge takes place from the rectum, but this is not chyle, it is only 
the changed mucous secretion of the irritated portion of the bowel. 
It is very curious to observe what different products the same set 
of secreting vessels will give rise to, according to the mode in which 
their vital action is afl^ected. 

In other cases the discharges from the bowels consist of fatty 
matter, which bears a strong resemblance to wax or adipocire. 
Again we may have them of a very dark, or even black colour. I 
have seen the stools quite black in particular forms of dyspepsia. 
Some time ago I attended a gentleman at Drumcondra, who ex- 
hibited this change in the colour of the intestinal secretions to a 
very remarkable degree. He was a very large man, accustomed to 
eat and drink very heartily, having, no doubt, a very capacious sto- 
mach and bowels, and a great quantity of fluids and solids. I 

* This patient speedily and perfectly recovered. 



406 GRAVES'S CLINICAL LECTURES. 

mention this in order to give some explanation of the enormous 
quantities of this black fluid which he passed by stool and vomiting. 
After complaining for a considerable time of dyspeptic sym.ptoms,he 
got an attack of vomiting ; and as he drank freely of diluents 
during the act of emesis, the quantity of this black fluid which he 
threw up was amazing; indeed, I might say, without exaggeration, 
that he vomited by the gallon. With this he had eructations of 
sulphureted hydrogen to such an extent, that it was almost impos- 
sible to remain in the same room with him. His tongue was as 
black as ink, and though frequently cleansed, resumed in a short 
time its former hue. He also passed an enormous quantity of the 
same stuff' by stool. This matter I ascertained, by numerous ob- 
servations and experiments, to be a secretion from the mucous 
membrane of the bowels, and not depraved bile or blood changed 
by the acid secretions of the bowels. Black stools may also depend 
upon the presence of other matters, as in case of melcena. Melsena 
consists of a discharge of gruaious blood from the intestines, either 
wither without black matter. The following is the way in which 
it occurs. Blood is secreted slowly into the intestinal tube ; while 
it remains there it is acted on by the acid secretions of the intes- 
tines, the effect of which is to change the colouring matter into a 
black, and in this state it is passed by stool. Again there are other 
cases in wiiich the discharges from the bowels are found of a tarry 
and viscid consistence, and having a greenish-black appearance: 
this would appear to be connected with a ^vitiated state of the biliary 
secretion. 

I have spoken here of three species of black discharge, each of a 
diflferent kind and requiring to have a distinction made between 
them for practical purposes. Now it is said, if blood be present you 
can easily recognise it by putting a portion of the discharge, 
inclosed in a small linen bag;, into warm water, when, after remain- 
ing some time, the linen will be stained of a reddish colour. If you 
take a portion of the tarry discharge, and drop a little of it into 
water, it will communicate to it a yellowish stain. On the other 
hand, the black fluid, which consists of vitiated mucous secretion, 
will not impart either a red or yellow tinge. 

I may further observe, that various substances used medicinally 
communicate a particular tinge to the alvine discharges. Thus 
acetate of lead, when it meets with sulphureted hydrogen in the 
intestines, changes the stools to a black colour. Again, many of 
the salts of iron have the same property. Other substances, such 
as logwood, bilberries, &c., impart to them a red tinge, while the 
continued use of chalk mixture is apt to render them whitish or of 
the colour of pipe-clay. This is apt to give rise to suspicions of the 
existence of obstruction of the liver; and in one instance I was 
deceived for some time by it myself. With respect to the greenish- 
coloured discharges, they are those which are most frequently met 
with, particularly in children, and are therefore entitled to a greater 
degree of consideration. There is nothing more common than to 



PECULIARITIES IN THE ALVINE DISCHARGES. 407 

meet with cases of this green discharge during the period of in- 
fancy ; and I regret to state that a great deal of error has prevailed 
on the subject. Greenish stools are generally looked upon as a 
sign that the child's liver is out of order, and as an indication for 
giving calomel. This, however, is by no means true ; they not un- 
frequently depend upon irritation of the intestinal mucous membrane 
approaching to inflammation. The proper mode of treatment here 
consists in adopting measures calculated to remove irritability. In 
such cases, warm baths, the application of rubefacient liniments to 
the abdomen, the use of antacids, such as chalk mixture, the carbo- 
nates of soda and ammonia, small doses of laudanum, and hydrarg. 
c. creta with Dover's powder, form the best remedies; and their 
operation will be very much assisted by a careful attention to diet. 
You will sometimes, it is true, meet with greenish discharges in 
adults, but then they are not so fluid as those of children, nor are 
they attended with the same irritability of the gastro-intestinal mu- 
cous membrane. Here the best plan of treatment is the Aberne- 
thian : blue pill at night, and a mild aperient in the morning, will 
be sufficient to correct the intestinal derangement, particularly if 
assisted by a well-regulated diet, and exercise in the open air. But in 
children the greenish discharge is often of a much more acute cha- 
racter, and more closely allied to inflammation, or rather irritation; 
although in some cases it may go on for a considerable time without 
producing any acute disorganisation. It is on account of the pro- 
perty which calomel and other mercurials, exhibited internally, 
possess of causing irritation in the first instance, and if pushed far- 
ther, inflammation of the mucous membrane of the intestines, that 
they are also apt to produce discharges from the bowels, copious, 
fluid, and mixed with green mucous flocculi, resembling closely 
chopped spinach. Sometimes the dejections consist of this green 
mucus nearly unmixed with anything else, and then they appear 
like semi-fluid boiled spinach. Now most practitioners think that 
this green colour is derived from bile which the mercurial has 
brought down in unusually great quantities from the liver, excited 
to a more energetic act of secretion. It has nothing to do with the 
bile in many cases, but is entirely derived from the irritated mem- 
brane of the intestines. Lon^ ago I pointed out, and was the first 
to point out, this fact, in the Dublin Hospital Reports. It has very 
important practical bearings. 



4r>f ^E^masaB^ams&DmjiiMaajiB^Si^ 



in: me mmsenzz — l^mr^e saa^mxj^^m^ — i^tteet. no: skmas^ -ics£:-r. cc. — ii 



jiBHititeatiB' tie fcssniESE .. — ; . :: ~:--i^ -vs:zsr:zL. 

ieiiE^imtgiiafcgaQ cc Tirmisi ':'>.i— .. ^aixiGHiscnD 

H jsiJT^ausEiir^'sstentey ttD ':te 3siiii^[rt ifimfiiEmzE .oErat^siifeETJiiin^ii 
ttL>^iiit mn sDiree ic tte wnmiiaal fisiruiESE ir -i^miiiTj sptCEsincsE liife* 
JK :tx tterr miute nf spreRiiiig, fmn nssssaE -wiicr uwse dimr liiiii- 
stDi: EntsftT' .ti> imnti^am. I smea: Hia: ciraiBSGoiaE ^dsnTiesis "WS75 
EumimTair^h- sIdw jn itearr xmcgi^s. xtttaiiiiii^ liifesir ms^s if 

tr aiffin: riEStnnrt shmssf uHe Enmimmir^ jet riifesaiit lESTDaia. iJi 
:tkt Dtitsr tiniui. -wiesTx bx SBuisinir ii^e rafiiKizsE. naass use TOirasap- 
snis. ^vsr^rthio^ edtibs imosr rfit mfiiEinst anm^: smuittarenuT" 
ami It D^csnsiiaimwt "tte ^^dmfie laoiiiitrj- :ir. tie ssuais ir r. jfev t t^ . 
Smih k tie EmnsE nt tie; ins^n: ^SDufemcn. mu: sr it: ^wia >wili: :tie 
mfusnsa xtf ILTTSS, "v^iiiiit TTEAslesi: rnnr tie skS; Hut Vest rrrsuss of 
iiE Tz^i^siir: BtiiiEfi: s?^^^- imaTBsr jot tre ^arbBS Hx "iiee jsase adi: 
^iifeinos ^ich trEA^:^e lie ^wimfe, irr iieer jy ^tie ^wtme sjiEat: if 
Ite iiiiBai)tE2ai ^iBQTtairi iif liesssitlijiilwraiifflite x mHter if '^tst 
inteissst Ti> 3ffiSEETtaiii 'tis; Tiim^ iff Iferr iFratt mnssHTaiiis. ur tresr 
Tmui: iff UEsimTttms. lEie i!lmi33iE uDxnnEsicsa:! jl Smnnsairi. Bnii m 
IS TDxree rfoltjowsf :tie ^rsBCt 'iness iff x^mmnimcaEiliiniBiu: jsTnnirerns 
IS ^lEsral Tiri^T^ss iiaE isssr imrti^^i^sess:.: im :it 3^'rii^,. Siaan. 
ami Utah', it ii^ tnrrslmz: ir "a-iitidise iinsr.iiais;: J^ j m cu i n^ ia>v^ 
svsT. ksms JLgsitsrB^ atni^ tie grgm irrtg^ nI iiiraiiiiimcmimi. .eHC- 
icg fcrai tie ^lart iff .tie jmontesr wiESSB :tt feit iirnfe ran. tz^vraircE 
"tie IHTSSE iDwiBE ii} iie iiresrini. lit sgrrriijaaiite iiia: m&snsE^ J^^" 
fii«s sirae isrlarn 3aiiii imimnr; miinsE. limfeeissiiiesir iff ttie mp^sca 
nrrcimiataiiiss "v^rtiist jstniis^. HissafamEai, ir sDoqiBSt :tie unurs:^ 
nf-^iatir cimeTE,. li s iiisk. tDD.ttm: IE mie if ssnrsimn^ ^ 
isuD^siTt XL iswsr Twaraiimis. Grmejaa tt»iii: p^saiSE xl icsiiDirmisSL j5 
ioiiTiB3y frDir. Siiuiistax :tt feiiairi;; dun. nice ssixmisiiaL tiesn.. ± 
TTmsi^ri -tie Atsmtir in xl sn^te itsp. ITte imiTnt iff nrfuEsnzL ii2j 
jint XB? y'sr isssTi mapfpasii du;. i).m,inin]Q lie HEiaiLUii& wmcrr nu/a^ 
i^sautfisii J3B,± fiissirs tr* rim^se imT^alki: ]^ iie SHire line ir t«s~" 
niferrsiit iiii2ntiDi& aTri?^ir^ ^ 'Il^aie TTuwii :ir Trniamr^ iiurmx 
iniL"Suimii2i, ami It Xamnnt m tie sane immtL. mnmr miL-wmer 



INFLUENZA. 409 

while it is reported to have reached New Holland, and to have 
raged among our antipodes, two months earlier. 

It is obvious that influenza does not depend upon mere variations 
of temperature, for we have had many seasons as changeable as 
the present, without the occurrence of any such epidemic. Besides, 
influenza is known to be a disease which travels through the most 
different climates, preserving its peculiar character and identity in 
all. It is not to be supposed that the same temperature, or the 
same barometrical and hygrometrical conditions of the atmosphere, 
prevail here as in Spain, France, Germany, or Sweden ; yet in all 
these countries the present influenza has exhibited an uniformity of 
character, and an identity of type, proving beyond all doubt that it 
is one and the same disease. That influenza is not produced by a 
low temperature, is proved by the occurrence of the disease in the 
month of June, in the epidemic of 1762; and in the months of May 
and June, in that of 1782 ; as well as by its appearance at the Cape 
of Good Hope in the middle of summer, as I have already noticed. 
At present, influenza is rather on the increase in this city ; and yet 
you have observed that, for the last week, the weather has been 
remarkable for its serenity and agreeable mildness. In London, 
many were led, by a limited view of the subject, to consider its 
origin as connected with the breaking up of the frost, and the 
pecuhar state of atmosphere attending a general thaw. Influenza 
is not influenced in its progress by situation or locality ; it does not 
creep along the shores, or follow the course of large rivers, or select 
low marshy districts, in preference to drier and more elevated 
soils. 

From what has been said, it is obvious that influenza does not 
depend upon vicissitudes of temperature, peculiarities of situation, 
or supposed moist or dry states of the atmosphere ; neither does it 
arise from the prevalence of certain winds, for meteorological 
observation furnishes many instances of the prevalence of such 
winds without any influenza ; and, on the other hand, it frequently 
travels against the wind. It is probable that influenza may depend 
chiefly on telluric influence — upon some agency connected with 
variations in the physical conditions which operate on the external 
surface of our planet; but on this point we can only speak con- 
jecturally, in the present state of our knowledge, and we should 
not allow ourselves to lapse into more speculative and fruitless dis- 
quisitions. How often the variations to which I have alluded 
occur, and whether they are subject to any general law, remains 
yet to be determined. 'Several epidemics of this description have 
been distinctly recorded in the eighteenth century, viz., in 1708, 
1712, 1729, 1732, 1742, 1762, 1767, 1775, 1782, 1789; while in 
the portion of the nineteenth century already elapsed, four influ- 
enzas have occurred, viz., in 1803, 1831, 1834, and 1837. This 
list is as complete as our medical annals will permit us to make it, 
but still we cannot rely on it as including all the epidemics of this 
nature which have occurred during the last one hundred and 

35 



410 GRATE S'S CLINICAL LECTI'RES. 

thirty-seven years. Supposing it correct, it would indicate the 
average return of influenza once every ten years. In making cal- 
culations of this kind, medical writers should always take care not 
lo confound influenza, or disease which spreads rapidly over the 
whole globe, regardless of season or climate, with those local 
catarrhal affections that occur in all teinperate climates almost 
annually. One thing, at least, is certain with respect to this dis- 
ease, that it does not arise from exposure to cold, or, as it is termed, 
from catching cold. This I have repeatedly observed. Persons 
who took the best care of themselves, who always went warmly 
clothed, and were never exposed to the inclemency of the weather, 
took the disease just as readily as the half-clad labourer, who had 
to undergo daily exposure to all the vicissitudes of our changeful 
climate. But it should be observed, that although the attack of 
influenza in any individual was not necessarily dependent on 
exposure to cold, yet in many instances it was evident that catch- 
ing cold determined the immediate access of influenza, or increased 
its violence when present. 

I have also observed, that it seldom attacked persons labouring 
under acute diseases, until the period of conFalescence arrived, 
when their immunit}' ceased, and they became just as liable to its 
invasion as others. Thus patients labouring under typhus escaped 
as long as the fever continued ; but frequently, on the very day the 
crisis occurred, and symptoms of returning convalescence appeared, 
they were seized with influenza. This is a very unfortunate cir- 
cumstance. Just as a patient had struggled through a fever of 
seventeen, nineteen, or twentj'-one days, he was attacked with a 
new and dangerous malady, which again placed him in a situation 
of imminent danger. 

You must have observed, that influenza does not appear in every 
individual with the same violence, or exhibit in all, symptoms 
identical in their intensity or duration. As in most other epidemics 
which affect society at large, the different constitutions and ag^of 
the individuals, and the different states in which the morbid influ- 
ence finds them, modify greatly the nature of the attack ; so that, 
although a vast number are affected, they suflfer in very different 
degrees, and the complaint exhibits every variety of shade, from 
simple coryza, or catarrh, requiring no treatment, to catarrhal fever 
of the worst and most unmanageable description. Many persons 
laboured under what would be termed a common cold, were it not 
from the extreme frequency of such symptoms, combined with 
other circumstances which mark the nature of the disease. The 
same thing was observed with respect to cholera: few persons, 
during the prevalence of cholera, escaped without undergoing 
some form of bowel attack ; but the mode and character of such 
attacks varied verj^ remarkably. It remains to be ascertained 
whether the poison which gives rise to intermittent fever, or to 
typhus, is also capable of being conveyed into the system in diflferent 
doses, and of giving rise to corresponding derangements of health. 



INFLUENZA. 411 

Dr. Rush brings forward many facts to prove, that when the causes 
of yellow-fever do not act with sufficient energy to produce in the 
constitution that particular form of disease, they may nevertheless 
occasion fevers of a less violent character, or may even give rise to 
chronic derangements of the general health, unaccompanied by 
fever. This is rendered more probable, when we recollect the 
great length of time certain poisons continue to exert a baneful 
influence on the health. Thus, Assistant-Surgeon J. W. Macauley 
informs me, that one officer and several men, inmates of the Royal 
Hospital in Dublin, are suffering from ague, the poison of which 
they imbibed in the ill-fated Walcheren expedition. 

Very lately, an officer of rank, much distinguished in the Penin- 
sular war, came from England to consult Mr. Crampton, Dr. Ken- 
nedy, and myself. Among other ailments, he was affected with 
evident traces of a vernal tertian, contracted in Portugal about 
twenty-seven years ago, and w^hich has seldom failed to return 
annually ever since. 

Influenza is not by any means so severe or so rapidly fatal a dis- 
ease as cholera, but the mortality which it has produced is greater, 
as it affects almost every person in society, while the ravages of 
cholera were comparatively limited. Consequently, although the 
proportion of deaths among a given number of individuals attacked 
was greater in cholera, the mortality for society at large is much 
greater in influenza. In Dublin, it is extremely difficult to obtain 
anything like exact statistical details of the comparative mortality 
at difterent periods, for no general registry of deaths is kept in this 
city. Through the kindness of Mr. Eiffe, secretary to the Caledo- 
nian Insurance Company, I have been enabled to get an accurate 
return of the interments in Prospect Cemetery, at Glasnevin, in the 
suburbs of this city, for the months of January and February, 
during which influenza was very prevalent, as also for the corres- 
ponding months of the preceding year. He has also furnished me 
with an account of the burials during the months before and after 
influenza. 

Interments at Prospect Cemetery^ Glasnevin ,- probably the largest in Ireland. 

In December, 1835, . . 355 In December, 1836, . . 413 

January, 1836, . . 392 January, 1837, . . 821 

February, 1836, . . 362 February, 1837, . . 537 

March, 1836, . . 392 March, 1837, . . 477 

Total for four months 1501 2248 

Increase during influenza, 747. 

Assuming, then, that in Prospect Cemetery alone, about seven 
hundred persons were buried who died of influenza, and that there 
are at least three times as many persons buried in the other church- 
yards of the city and suburbs, we may conclude that in Dublin 
alone more than four thousand people died of the influenza, not 
taking into account the great number who, although they got over 



412 GRAVES'S CLDJICAL LECTURES. 

the immediate attack of the epidemic, sank afterwards under 
various diseases, of which influenza had laid the foundation. In 
Paris, the influenza caused likewise a great mortality; for it 
appears, from a statement in the Revue Medicale, that the average 
daily mortality, during the first fifteen days of Februarv, amounted 
to one hundred and ten, which is more than double the usual 
average. This only refers to persons dying in their own houses, 
and does not include the deaths in hospitals. Eighteen thousand 
die in private houses annually in Paris — i.e., on an average about 
fifty daily. The rate varies from twenty to seventy a day, accord- 
ing to the season; but during the first fifteen days of February, it 
rose from fifty-eight to one hundred and fifty-two in the day. 

Influenza has been very fatal where it attacked persons who had 
been subject to chronic bronchitis, or who had happened to labour 
under any form of asthmatic affection : for this, I confess, I was not 
quite prepared. And when first called to attend asthmatic persons 
labouring under influenza, I expected that, from being accustomed 
to periodic attacks of dyspnoea and cough, they would be belter 
qualified to bear the disease, and would continue to exhibit that 
tenacity of life for w^hich asthmatic persons are so remarkable. 
The old also suffered considerably ; but some very old persons had 
extremely severe attacks of influenza, and yet escaped. I attended, 
along with Mr. Maurice Collis, the venerable Judge Day, the co- 
temporary of Goldsmith, who, at the age of ninety-three, had suffi- 
cient strength of constitution to shake off* a most violent seizure. 
Two gentlemen, who had fought at the Battle of Bunker's Hill, also 
survived the disease in a severe form ; but generally speaking, it 
was verv fatal amonor the acred. Influenza was also verv fatal 
among persons who laboured under disease of the heart : and in this 
instance, age made no difl^erence as to result, for the young and 
old were equally liable to danger. I have also seen it fatal in cases 
of deformity of the chest, from curvature of the spine, and other 
causes. The mortality was also very great among persons in ad- 
vanced life who laboured under tussis senilis : in a word, all persons 
labouring under pulmonar}^ irritation, or weakness, were exposed 
to ver}^ considerable danger. Subsequent experience has proved 
also, that where influenza left behind it an obstinate and irritative 
cough, and where the constitution had a scrofulous taint, the disease 
was very apt to pass into tubercular phthisis. Among all the fami- 
lies I know, but two escaped the influenza altogether : one consisted 
of eleven children, besides the parents and servants, and resided in 
Pill Lane, in the very centre of the city ; the other consisted of five 
females, advanced in life, and who lived in one of the fashionable 
streets. 

Allow me to digress here for a moment, for the purpose of 
making one observation, which a review of several cases of influ- 
enza, attended with severe pulmonary symptoms, suggests to me. 
It is a common error in pathology to confound efi^ects with causes, 
and where the cause of a disease is not, and probably cannot be 



INFLUENZA. 413 

known, to fix on some peculiar and leading symptom^and attribute 
to it the origin of all the rest. But it is quite illogical to say that 
one symptom is the cause of another, or that because it has the 
precedence, it should also have the initiative. I alluded to this 
error in a former lecture, when speaking on the pathology of scar- 
latina. It has been over and over again asserted, that the dropsy 
of scarlatina arises from the previous inflammatory affection of the 
skin, or subcutaneous tissues; and the same thing has been asserted 
with regard to the desquamation of the cuticle. But I have brought 
forward facts and arguments to prove that this opinion is not founded 
in truth, and that dropsy, as well as desquamation of the cuticle, 
may take place where there has been no eruption whatever, and 
not the least trace of cutaneous or subcutaneous inflammation. 
Now when a person, after exposure to cold, gets pneumonia or 
bronchitis, followed by anasarca, it is quite a common thing to hear 
it said, that the anasarca had its origin in the pulmonary affection, 
and that the effusion of serum depended on obstructed transmission 
of blood through the lung. The same mode of explanation has been 
applied to disease of the heart as the cause of dropsy. This expla- 
nation, however, appears to me inadequate and unsatisfactory. 
Many cases of influenza were accompanied by extreme congestion 
of the lungs, and consequently imperfect aeration of the blood ; and 
yet I have not in a single instance noticed the occurrence of dropsy 
as an immediate or remote consequence. Were dropsy dependent 
on the state of the lung to which I have alluded, it would have 
shown itself in some cases at least; and yet I have seen individuals 
attacked with influenza labouring under orthopnoea and severe puU 
nionary symptoms for weeks, without observing, in any instance, 
the slightest anasarca or oedema.* This has strongly impressed 
upon my mind the conviction, that when dropsy comes on after 
disease of the lung, that the one is not always the consequence of 
the other, but that both often result from the samo cause, and owe 
their origin to the same morbid impression on the system. This 
error has been further confirmed by the results of treatment, prac- 
titioners having found that measures adapted to remove congestion 
of the lung tended also to remove the dropsy ; forgetting here, that 
where two symptoms closely allied together arise from the same 
cause, you will be most likely to relieve both by those means which 
are effectual in removing either. The principles which I have here 
briefly alluded to, will apply to many other combinations of disease ; 
it is one of general application, and, in my mind, of no ordinary 
importance. 

The present epidemic differs in many points from that which 
prevailed here about three years ago. The influenza of 1833-4 
ivas by no means so generally fatal as the present. It was charac- 

* I saw one old genfleman at Rathmines, whose feet and legs were much 
swollen ; but this I attributed to his having remained so many days and nights 
in his chair, unable to lie down. He was under Mr. Crampton's care, and re- 
covered, 

35* 



414 GEATES'S CUMCAL LECTCUEfi. 

^fwd, lifce the present, br considerable initali©!! «^ tfae aimcfceal 
aud broDchial mD: f .e, but sol by the ssvm^ hrDDtAaiis 

and pneumonia wn.-- t . r^n Trifnessed in many <cases ©f libe 

present disease. The r .-^aged in Dablin ci»efly ims^ lie 

monins of March sjid Ji.}Jiu . ii came on very suddenly, "W'itb rapid 
paise, hot skin, great prostration. iangaoT.and exc^siye sweating -: 
^ere was c&a^ coiyza, i . ; . " f : : f 

'ComtDsncsiBSB^ vws oi ir. v 

■was headache, which was excessively :-'^ - ~ - . i-isc. 

coikris Tj.i-^'bus. njo-e ce^-ilhj, and thep: _::_ i :.i i: ti: , :eed- 
:: r ; ; "" : ; t ; roe at present. Bat the mosi material 

r: ~-..o.. -^^z" : i- f "■? r"-'"'r'^'^'f*'^? '""•or^dity, Tl)e dis- 

f : 7 : SM carr.'i : : r t ; n MiEiBra] STmp- 



coDv : On tD: t i t : : ccompa: 

of 15-^ v"^^ ?:: - T v, /.niDare r 

of ihr : : -- r.iofa aisteraib 1: 



?.al swaec^f 



^ : ; _ f a gaiae : : : t': 

between thee: : : st — smc r ; a more fixe c 

and arailabie i^Di " t _ t ^ ..je laajBreanc :.,l j..j oi epiififflic coid- 
plaints. 

There are. I hav£ lio wdiss&i, wammf coanbis ieams of ffwiismir 
disease which pass a iiwM^ SBsasAy dsAner winalf OBDiiflaeei, oi 
coaiMHided ^^1^^ ^adiesis to wiicii ite^ iaavie soaie s^te affintr. I 
tkiiSL I l»Te sees paru^ab forms <if scailal^nL, m ea ^ KS, small- 
pox, and hver, which have not been aecaraaSefy «©ted, althoog:. 
ihey prevailed as epidemics. If e«®iyibmarfefilBBMCwafiJwa4ed. 
and the order of its successioai Hooi^sdl, it «»ild leanaaa to br 
ascertained by ^^simiij, wi^iksr lieve fnay not ibe wlnt snsj be 
termed cycles of Cfadeanics, aoad ivfes&er fecgHgi, siter Irs^^r 
manifested itself in deiendiBate imns, fislsawTOg each ' : - 
determinate st^t^asasaa, mayBoit ctMnrianmce asraiL e:^"-:t trr 
a certain number of years, and pnrsue the : 
Dot impossible, if we suppose that ^-'-'f--' : ^ . . . . 
telluric or electrical infiuences, wh;: t - _ :: - . _ -- z : 
periodic course. Were i: 
^idemics could be -easily -: . . 

In treating of the nature oi t.i& prese: " t : 
proper to consider, in the first place, the _ t t i : . : ; 
symptoms which attend it, and afterwards glance at in iz " 
are chiefly of a local descriptioii. In some cases of inflae:.:.-. „,.:-. 



INFLUENZA. 415 

is little or no fever ; neither does the presence of fever seem essen- 
tial to the more severe or even fatal cases, although, generally 
speaking, fever occupies a very prominent position among the 
group of symptoms by which the disease is characterised. 1 have 
seen cases in which there was nothing like regular fever from be- 
ginning to end, and yet which terminated fatally. 

I am at present treating two patients who have been labouring 
under orthopnoea for the last ten days, and yet in these patients 
the skin is cool, the pulse in general soft, and very little above the 
normal standard, and the tongue, though furred, quite moist ; yet 
so great is the distress of respiration, that they are obliged to 
remain sitting up in bed night and day, panting for breath ; and I 
am of opinion that both will die. This, hovi^ever, is the exception 
with respect to severe cases, the majority being attended with very 
considerable fever. In the slight cases, the fever is scarcely per- 
ceived, or altogether absent; this w^as the case with myself and 
some of my friends. We had coryza, hoarseness, cough, and some 
degree of pulmonary irritation, witiiout any fever. At first, I 
thought that fever was an essential part of the disease; but the 
cases to which I have alluded, and others of a similar kind, have 
convinced me that this is not the fact. Where the fever appears, it 
comes on with the usual symptoms of pyrexia — namely, sense of 
chilliness, particularly about the small of the back, without decided 
rigors, flying pains in the limbs and joints, and headache, generally 
referred to the situation of the frontal sinus. There is, from the 
commencement, great restlessness, jactitation, and more or less 
insomnia. Sickness of the stomach, loss of appetite, and tendency 
to diarrhoea, are also common symptoms. The skin is in general 
hot, and without any tendency to moisture, although, in some 
cases, there are occasional perspirations. These, however, are 
seldom general or regular, and last only for a few hours. The 
pulse is accelerated and tolerably full, occasionally even hard and 
wiry. These symptoms are very subject to slight exacerbations 
and remissions, and seldom continue the same for more than twelve 
hours together. Where the disease exists for any length of time in 
a violent form, the tongue usually becomes furred and loaded, the 
patient loses all relish for food, and in many cases complains of 
harassing thirst. In severe cases, the most prominent symptoms 
are cough, wheezing, restlessness, dyspnoea, and loss of sleep. 
The appetite is generally more or less impaired; but I have seen 
some severe cases in which it did not fail remarkably for several 
days ; the restlessness and jactitation attend many cases throughout. 
You are not, however, to suppose that this always depends on the 
presence of pain or fever. The headache is not in all severe or 
distressing, and I have already stated, that the fever is not so 
general or so violent as one would suppose. The loss of sleep 
depends upon derangement in the tone of the nervous system, 
independent of fever ; for I have observed it in numerous patients, 
in whom scarcely any febrile excitement was observable ; but when 



41C GEATES'S CLIMCAL LECTUBES. 

complicated with ferer, both react upon and aggravate each other. 
The skiD. where ferer is present, is hot : this heat is interrupted by 
occasional perspirations, which, however, do not give much relief, 
or tend to diminish the amount of increased temperature. Some- 
times the skin is hot, and at the same time bedewed with perspira- 
tion daring the whole course of the disease : hot this is rather 
unusuaL The pulse is seldom the same throughout: one time 3'ou 
will find It quick and rather tiard : in six hours afterwards it w^ill 
be quick and soft ; in six or eight hours more it will appear as if 
about to fail to the normal standard, and next day you will find it 
quick and jerking again. These changes are accompanied by 
corresponding alterations in the temperature and humidity of the 
skin. But what is most remarkable with regard to the pulse is, 
that it sometimes becomes full, and rather strong and wiry, towards 
the termination of the disease : and this you will observe in patients 
who have been suffering for days, or even weeks. I have been 
attending for the last fortnight, with Mr. Colles, a gentleman in 
Castle street, aged sixty, of a full habit, and subject to attacks of 
dyspncea and cough during winter. This gentleman was attacked 
wuth influenza, ushered in and accompanied by severe fever ; and 
it was observed that, as the disease advanced, his pulse became 
fuller and stronger, so that it was thought advisable to bleed him. 
He was bled with apparent relief, and the blood was extensively 
belied and cupped. This phenomenon I have observed in every 
case attended with fever, and indeed in some where no appreciable 
fever existed. Thus, a gentleman in Dame street, who had no 
fever, and w*ho merely laboured under teazing cough, distress of 
respiration, and oppression of tbe chest, the blood, on being drawn, 
exhibited very distinct buffing and cupping. The same thing hap- 
pened in the case of a geniieman, in Dominick street, whom I 
ordered to be blooded under exactly the same circamstances. The 
gentleman in Castle street, whom I attended with Mr. Colles, 
exhibited a very curious state of pulse. In him, as in many 
others, the poise was extremely variable as to its strength, being at 
one time hard and firm, and at another soft and weaL If you 
were to visit him in the morning, from the feel of the pulse you 
would be inclined to give him stimulants : if you saw iiim for the 
first time on the evening of the same day, you would think vene- 
section indispensable. This gentleman's state was hopeless : he 
laboured under great suffering, dyspnoea, and inability to cough up 
the viscid mucous secretion, and yet his pulse was both strong and 
firm. Mr. Colles, whose attention I directed to the state of the 
pulse, observed, that were he to feel it without seeing the patient, 
or knowing his previous history, he would be greatly inclined to 
bleed him immediately. I have adverted in a former lecture to 
this state of the pulse, as connected with irritation of the nervous 
svstem, rather than "with any inflammatory state of the constitution 
in s"snerai, and therefore I shall not now recur to the subject, 
furtner than to remark, that I have nevex^ observed anv disease in 



INFLUENZA. 417 

which the pulse formed so bad a guide as to the propriety of vene- 
section as the present epidemic. In some cases, venesection was 
most useful, although the pulse was in every respect natural ; in 
others, it could not be borne even to the smallest amount, although 
the pulse was hard and wiry. Neither was the state of the blood 
an unerring guide, for even in those who sank rapidly, from the 
debilitating effects of moderate bleeding, the blood was very much 
cupped and buffed. 

Before I conclude, I shall mention the particulars of a very 
remarkable case which came recently under my notice. I was 
called to visit a lady, somewhat advanced in life, but of a good 
constitution, and labouring under the ordinary form of influenza, 
with considerable dyspncea and cough. In the course of eight or 
nine days, her symptoms began to decline ; she got up, and seemed 
convalescent. As the cough and pulmonary irritation still pre- 
vailed to a certain extent, it was thought advisable not to allow her 
to eat meat, but she obtained leave to take some fresh haddock. 
After dinner, her cough becoming more troublesome than before, 
she had frequent recourse to a stale and rancid cough-bottle, con- 
taining squill and ipecacuanha. During the evening and night, she 
felt her dinner like an undigested load, and her stomach turned. 
She vomited, and was purged and griped incessantly, until I saw 
her next day. On the third day, the medicines I had ordered mo- 
derated the purging, but the nausea and occasional vomiting con- 
tinued. On the fourth day, the purging had entirely ceased, but the 
sickness of stomach persisted. I sought to appease this by the ordi- 
nary means, which failing, I examined her with care on the follow- 
ing day, and discovered a strangulated hernia. At this time the 
pulse had scarcely risen above the natural standard. Mr. Cusack 
operated that night with his usual skill, and all the symptoms de- 
pending on incarcerated hernia ceased. But they had scarcely 
disappeared, when the pulmonary symptoms, and the copious secre- 
tion from the bronchial tubes, recurred, and she did not survive this 
relapse of the influenza more than a few^ days. 

This is an instructive example of an insidious combination of 
circumstances very likely to mislead a practitioner. For as the 
vomiting was for a day or two accompanied by a looseness of the 
bowels, the suspicion of hernia would not strike the attention. It 
is plain that in this case indigestion produced an increased and 
morbid activity in the motions of the alimentary canal, which led 
to the incarceration of the portion of gut. Up to a certain moment 
the symptoms depended merely on one cause; after that period, 
strangulation took place — an occurrence which could not be easily 
diagnosed, as vomiting, one of the most striking symptoms, had 
previously existed. 



418 . GRATES'S CLLMCaL LECTCRES. 



LECTrRE XX. 

mtNTtem mpgez.r:i- — Zz:^::.: :: — 1.:_ :j_r r:-": 

ter of die ^ota. — A: vfi:: ;;f5 :: ::.r ::.::. r — I : 

be tasapiojei. a: : f :i ? r : — : i t s ; ::;::- 

ters geoaaJfy —i±::z-: — "^' irz. ::zizz:-r.:::.i IfcaeikiML 

Is my last lecture I ailaded U> the afi^tion of the intestiDal canal 
in iaflueaza, and stated that in many cases there is derangement of 
the digestive tube — as manifested by thirst, anorexia, naosea, or 
even vomiting, and a tendency to diarrhoea. When diarrhoea 
occurs, it is generally at the commencement of the disease ; and 
it is remarkable that this state is frequently exchanged, rather sud- 
denly, for one of an opposite character. Thos, when yon have 
succeeded in checking the diarrhcea with chalk mixture and opium, 
a state of costiveness will frequently ensue, requiring the daily use 
of purgatives and eneraala. I have now witnessed several cases 
in which the moderate use of opiates and astringents brought on 
constipation, requiring the use of strong purgatives and enemata, 
throvfn up with Read's syringe. 

In influenza, as in many other febrile affections, tlie lungs become 
considerably engaged ; the disease first attacks the nose and throat, 
then the lar}^^ and trachea, and, finally, the ultimate ramifications 
of the bronchi. There are several other afiections which com- 
mence in a similar way — as ordinary catarrh, bronchitis, and 
measles. In influenza, most persons have the nose and throat 
affected in the beginning ; the inflammation creeps ^^dually along 
the lining membrane of ihe air passages, until it involves the 
greater part, or the whole, of the bronchial mucous membrane. 
The progress of the inflammation is extremely rapid, and in the 
course of twenty-four, or even twelve, hours the lungs become 
engaged. There is, however, much di^rence as to the extent to 
which this inflammation proceeds. In many cases, it is limited to 
the nose and throat ; the patients complain of coryza, hoarseness. 
and slight cough. In others, the trachea also is more or less 
affected, and the cough is more troublesome ; but generally speak- 
ing, the latter as well as the former cases are unattended witr. 
fever. The patients eat and drink as usual, go about their ordinary 
business, and sleep tolerable well at night. This appears to be the 
general course of the disease when the inflammation is limited to 
the, nose, throat, and upper part of the air passages ; when it spreads 
farther, and attacks the first ramifications of the bronchi, there is 
some dyspnoea and tightness of chest, the cough is much more 
troublesome, and the appetite and digestion are somewhat impaired : 
but persons in this state, although resting badly and eating but 
little, will continue to go about — constantly, however, complaining 
that they are very ill. When the smaller divisioBS and ultimate 



INFLUENZA. 419 

ramifications of the bronchi are engaged, there is soreness of chest, 
remarkable dyspnoea, and constant harassing cough ; the headache 
is also aggravated, the patient loses all inclination for food, sleeps 
badly at night, and is confined to the bed or house. First, then, 
you have the mucous membrane of the eyes, nose and throat 
affected ; then the larynx and trachea ; then the larger bronchi ; 
and finally, the smaller and more minute ramifications. When 
the latter state has continued for some time, more or less serous 
engorgement of the lung takes place, and this adds to the dyspnoea 
and cough. On applying the stethoscope over various parts of the 
lung, you will hear at various parts a moist crepitus, indicating the 
existence of serous infiltration. The smaller bronchial tubes and 
air vesicles are congested and filled vt^ith mucus; the blood cannot 
pass freely through the lung, and consequently must be imperfectly 
aerated ; the secreting and absorbing functions of the lung are 
deranged, and hence arises a state in which the pulmonary capil- 
laries become congested, and permit the more fluid part of the blood 
to exude into the parenchyma of the lung, giving rise to what is 
termed serous infihration. Something similar to this occurs also 
in general bronchitis, particularly in fever, but we very seldom 
have hepatisation resulting from such causes. In hepatisation, the 
capillaries pour out, not serum, but lymph, which glues together 
the cells of the pulmonary tissue, and forms a dense solid mass. 
Hence, in influenza or bronchitis, you seldom have true pneumonic 
inflammation. You will have extensive and dangerous engorge- 
ment, but when you examine the lung after death you do not find 
any real solidification, and you can restore the lung almost to its 
original permeability and buoyancy by squeezing out the infiltrated 
fluid. Yet I must admit that this is not always the case, and that 
in influenza, as well as in bronchitis, you may have true pneumo- 
nia superadded to the original affection of the lining membrane. 
This occurred in the case of a lady whom I attended in Chapel street, 
and who was attacked with influenza shortly before dehvery* On 
the day of her accouchement, pneumonia was superadded to the 
bronchial inflammation, and she died with extensive hepatisation 
of the right lung. This also occurred in the case of a man of 
middle age, residing in Suffolk street, who had been labouring for 
some days under excessive engorgement of the lung* I have also 
observed the same occurrence in a gentleman whom I attended 
with Mr. Colles, in Exchequer street ; and in another case which I 
saw in Whitefriar street. 

One of the most singular features in the history of the present 
influenza is the extraordinary degree of dyspnoea witnessed in most 
cases where the lung is extensively engaged, but particularly where 
the patients had been previously subject to pulmonary affections ; 
and even in many cases where the bronchial mucous membrane is 
but slightly engaged, the amount of dyspnoea is remarkably great. 
Indeed, it might be said with much truth, that the dyspnoea was by 
no means proportioned to the extent of pulmonary inflammation. 



420 GRAVES'S CLINICAL LECTURES. 

There is at present in the hospital a woman labouring under influ- 
enza, whose chest sounds clear on percussion, and in whom every 
part of the lung is permeable, who presents nothing more than a 
few sonorous rales in the course of the larger bronchial tubes, and 
yet she is suffering from considerable dyspnoea, and the respirations 
amount to forty-six in a minute. We cannot, therefore, attribute 
the difficuhy of breathing to mere bronchitic lesion, for it is not in 
proportion to this lesion. Another patient admitted into Sir P. 
Dun's Hospital exhibited a similar train of symptoms. He was a 
negro sailor, a native of New Brunswick, and was seized with the 
epidemic a few days after his ship arrived in Dublin; he was a 
man of Herculean form and finely developed chest, and in the 
prime of life. His suffering from dyspnoea was intense ; his chest 
heaved, he tossed about in bed in a constant state of agitation and 
restlessness, and yet the respiratory murmur was everywhere dis- 
tinctly audible through the lung, and no rale could be heard, except 
here and there a few bronchitic wheezings. He also laboured under 
insomnia, and, though he had but little fever, his debility was ex- 
treme. Indeed, his pulse was so weak from the commencement, 
that I could not venture to treat him antiphlogistically ; and I 
accordingly ordered extensive vesication over the chest, with the 
use of wine, stimulants, and narcotics. This man subsequently 
recovered — an event which could scarcely have occurred under 
the plan of treatment adopted, had his dyspnoea depended on mere 
bronchitis. It should be also borne in mind, that in many bad 
cases of influenza the dyspnoea is intermittent, or at least undergoes 
remarkable exacerbations and remissions at certain hours of the 
day and night. It would appear that the respiratory derangement 
depends on the same general cause which produces the whole train 
of symptoms, and that it might exist even where there was no 
bronchial inflammation at all. It is true that where the bronchitis 
is present, it adds to the distress of respiration, but the dyspnoea 
appears to be chiefly attributable to some impression made on the 
vital activity of the lung. That the lungs are endowed with an 
inherent vitality necessary to the aeration of the blood has been 
long acknowledged by the Germans, who have described a dyspnoea 
from paralysis of the lungs ; and this opinion is now generally 
adopted in^Great Britain, since the results of the experiments on 
the eighth pair of nerves have been duly appreciated. We have 
abundant illustrations of this truth in asthma, in which the greatest 
dyspnoea is often present without any appreciable lesion of the 
lung. And it would be a fortunate circumstance for the patients 
in influenza, if this were not the case; for we could then treat the 
affection of the lung as ordinary bronchitis, and should expect to 
find it amenable to the ordinary remedies. You are aware that 
the mortality in cases of ordinary bronchitis is extremely small, if 
we except very young children and persons advanced in life. In 
adults, when met by prompt and appropriate treatment, it is in 
general a very manageable disease, and seldom proves fatal unless 



INFLUENZA. 421 

combined with other unfavourable conditions. This, however, is 
not the case in influenza, nor is the puhnonary affection so easily- 
treated, or the dyspnoea so readily controlled. I saw, some time 
ago, a fine young woman, servant to a gentleman in Fitzwilliam 
street, for whom everything had been done which the best and 
most skilful practice could devise; but her condition, when I saw 
her, was desperate, and she died the following day ; yet her chest 
sounded well on percussion, and we could hear nothing over the 
whole lung except a few sonorous and sibilous rales, and the respi- 
ratory murmur seemed everywhere nearly as loud as natural. Of 
course, such a lesion of the nervous influence could not last long 
without necessarily inducing pulmonary congestion — an inevitable 
consequence of imperfect aeration of the blood. When the eighth 
pair of nerves is divided, the animal is slowly suffocated ; and, on 
dissection, the lungs are found engorged, and the bronchial mucous 
membrane congested and inflamed. May not the affection of these 
parts in influenza be sometimes induced by lesions of nervous 
power in the lungs 1 I am indebted to my friend, Dr. George 
Green, for the following results of his very numerous post-mortem 
examinations in this disease, and I feel great pleasure in being able 
to give them — as such examinations, at least in this country, are 
very rare. Dr. Green observes : — 

" The cases which proved fatal at the House of Industry, during 
the late epidemic influenza, occurred principally among the aged 
inmates of both sexes. I had an opportunity of examining several 
of these cases, and the following were the principal post-mortem 
appearances observed. 

" The bronchial mucous membrane was found, in every case, 
more or less congested and inflamed. The colour varied consider- 
ably — being in some of a dull red, and in others of a much darker 
hue. The inflammation, in most cases, was found to occupy both 
the trachea and the bronchial tubes of both lungs ; in other in- 
stances, it was confined to one lung alone. A sanguinolent frothy 
mucus occupied the area of the tubes, and increased in quantity as 
they were traced to their minuter divisions. The parenchymatous 
tissue of the lung was invariably discoloured, being generally of a 
dark or violet colour; its specific gravity was increased, and it did 
not crepitate, or at least very feebly, when pressed between the 
fingers. The surface of its section was not rough to the touch, and 
when pressed in the hand a quantity of the mucus described above 
was driven out. In some cases, the postero- inferior portions of 
one or both lungs were very dark coloured, and the finger could be 
passed easily through its substance. When the surface thus torn 
was examined, it did not appear to be granular; it resembled more 
a portion of gangrenous lung, except that there was an absence of 
fetor. This last appearance was found principally in very aged 
persons. It was rare to find any traces of the second and third 
stages of ordinary pneumonia in these patients ; but in the young 
and robust, who were received into the Hardwick Fever Hospital 

36 



422 GRAVES'S CLINICAL LECTURES. 

from the neighbouring streets, these degenerations of the structure 
of the lung were observed, together with the same inflammation of 
the bronchial mucous membrane. 

In most of the aged patients, the blood was found dark coloured 
and fluid in both cavities of the heart, and in every vessel where it 
was examined. The cases in which fibrinous concretions in the 
cavities of the heart were found, were very few, and these inva- 
riably in the young or middle aged. In the former class of patients, 
also the lung occasionally appeared to be (edematous; and, in one 
or two cases, a considerable efl'usion of serum had taken place into 
the pleural cavities. The signs of recent pleuritis were very rare, 
but old adhesions, as might be expected in such subjects, were very 
commonly found between the pulmonary and costal pleurse. In 
one case of a lunatic, who survived the immediate attack of influ- 
enza, tubercles appeared to have been rapidly developed in both 
lungs. In another lunatic, two tubercular cavities were found in 
addition to the state of the lung and air-tubes already adverted to. 

"With respect to the nature and duration of the symptoms of 
those cases which caine under my own management, I have little 
to say in addition to what is already so familiarly known. The 
physical signs aflx^rded by percussion and auscultation were almost 
universally as follows : — Dulness, more or less decidedly marked, 
in the postero-inferior portions of the lungs ; sonorous or some 
form of the bronchial rales throughout the chest, or, what was more 
common, a mixed sonorous and crepitating rale, or, in the latter 
stage?, a muco-crepitating rale. The sputa were seldom rusty- 
coloured or tenacious, but rather resembled those of bronchitis. In 
many cases, the want of power to excrete them appeared to be the 
immediate cause of death ; but in others, the morbid cause, what- 
ever it might be, appeared to have aflTected the entire respiratory 
and circulating systems, producing great congestion of the venous 
system, and a state not unlike asphyxia. The latter cases were 
almost all among the aged inmates of the House of Industry. 

The appearances of the other viscera were not such as could in 
any way account for the result, so often speedily fatal; so that, so 
far as one could hazard a conjecture, the morbid cause appeared to 
have made its primary impression on the respiratory mucous sur- 
face, thereby interfering with the proper aeration of the blood, and 
inducing the changes in that fluid and in the structure of the lungs 
above detailed." 

Such are the appearances observed by Dr. Green in his nume- 
rous dissections of persons who died of influenza. They may be 
relied on as perfectly accurate, for no one is better acquainted with 
pathological phenomena than Dr. Green, and consequently no one 
better able to furnish valuable evidence with respect to the appre- 
ciable changes produced by influenza in the pulmonary and other 
tissues. 

I have already advanced the opinion, that we should not hastily 
assume that influenza consists essentially in the morbid changes 



INFLUENZA. 423 

which dissection reveals; we should examine every side of the 
question, and consider whether it is not possible that the alterations 
in the pulmonary tissue may not be, to some extent at least, the 
consequences of the disease. Let us consider for a moment the 
method we pursue in reasoning about the progress and causes of 
the symptoms in ordinary bronchitis. Here a patient is seized with 
a pectoral affection, attended by cough, dyspnoea, and more or less 
fever. We find certain rales, and the expectoration is altered in 
quality and quantity. Further, observing a number of such cases, 
we remark that the danger is proportioned to the degree of dyspnoea, 
and the dyspnoea to the extent and nature of the rales, together 
with the quantity and quality of the expectoration. To these the 
general constitutional affection, and the probable results of the dis- 
ease, have certain definite relations, a knowledge of which is soon 
obtained by experience. But these rales, and this state of the 
respiration and expectoration, we have reason to believe, arise from 
the presence of bronchial inflammation; and to this we refer all 
the symptoms observed. On this supposition, too, we proceed in 
our treatment, and the result most commonly justifies its correct- 
ness; and we have additional evidence of its truth furnished by 
post-mortem examinations. Now, in such instances, the chain of 
inductive evidence is complete, and we feel a conviction that our 
practice is founded on correct notions of the nature of the disease. 
But how different is the case when we assume that influenza is 
caused by bronchial inflammation ! In influenza, the dyspnoea is 
not always proportioned to the bronchitic affection — nay, in some 
cases we have seen that difficulty of breathing was most urgent in 
cases where the air entered into all parts of the lung with facility, 
and where few and unimportant rales existed. Again, although 
the presence of a copious viscid secretion in the bronchial tubes 
was sure to aggravate dyspnoea, yet it often occurred in patients 
whose air-passages were very little, or not at all, obstructed in this 
way. The effects, too, of remedies, antiphlogistic, expectorant, and 
derivative, were very different from what they would have been 
had the disease depended on a mere bronchitis. I have already 
stated my conviction, that the poison which produced influenza 
acted on the nervous system in general, and on the pulmonary 
nerves in particular, in such a way as to produce symptoms of 
bronchial irritation and dyspnoea, to which bronchial congestion 
and inflammation were often superadded. 

In this view of the subject I am not singular, for I find that it 
has been advocated by Dr. Peyton Blakiston, in a short treatise on 
influenza, as it occurred at Birmingham. He states that his re- 
searches have led him to the conclusion, " that influenza is an 
affection of the nervous system, with its concomitant derangements 
in the organs of digestion, circulation, &c., commonly known under 
the name of nervous fever, accompanied throughout its whole 
course by irritation of the pulmonary mucous membrane, which 
not unfrequently amounts to congestion, and even to inflammation." 



424 GRAVES'S CLINICAL LECTURES. 

This distinction between influenza and feverish cold with bron- 
chitis, is, in a practical point of view, of great importance, and 
should never be lost sight of in the treatment of influenza — for it 
prevents us from placing our sole confidence in remedies adapted 
to mere bronchitic inflammation. Thus, Dr. Blakiston asserts, and 
most physicians will agree with him in this point at least, that it 
was often necessary to have recourse to diff'usible stimulants at the 
commencement, and to administer tonic medicines in an early stage 
of the disease. 

In some cases, even where great dyspnoea exists, the cough is 
hard and dry, and the expectoration scanty ; in others, the expec- 
toration is copious, so as to cause constant efforts to cough it up ; 
and, indeed, it is melancholy to look at the distress which patients 
suffer in this respect. You will hear the wheezing of the phlegm 
in the throat and air-passages before you enter the room, and yoii 
will see the patient exhausted by successive paroxysms of cough, 
and ineffectual attempts to expectorate. In other cases, where the 
vitality of the lung is less injured, and the general tone of the sys- 
tem less deranged, the sputa, although copious, are expectorated 
with considerable facility. The sputa bear considerable analogy to 
those observed in ordinary bronchitis ; they consist at first of a 
grayish mucus, which, as the disease proceeds, exhibits a globular 
appearance, or assumes a puriform character, and does not coalesce; 
in other cases they are extremely viscid and ropy, like solutions of 
gum or isinglass. A remarkable fact with respect to the sputa in 
influenza is, that they are very seldom mixed with air-bubbles. On 
mentioning this to-day to some persons attending my class, I was 
shown some sputa discharged by a patient labouring under influ- 
enza, in w^hich there were some air-bubbles ; this, however, is 
extremely rare. In a lecture which was delivered here some time 
ago, I took occasion to allude to the secretions of the bronchial 
mucous membrane, and stated my conviction that this subject had 
not received as yet the attention which its acknowledged import- 
ance demands. There is one point, in particular, of which no ade- 
quate explanation has been as yet given — namely, why it is that in 
some cases of pulmonary inflammation the sputa are filled with 
air-bubbles, while in other instances there is no appearance of air- 
bubbles from the beginning to the end of the disease. The presence 
of air-bubbles in the spula has been explained, by supposing that 
air becomes incorporated with the mucus while it is driven up and 
down in the bronchial tubes during the acts of respiration and 
coughing ; just as if you shake a solution of soap or any other 
viscid fluid in a half-empty bottle, it becomes impregnated with air- 
bubbles. There may be some truth in this, but I think it does not 
sufficiently explain the presence and intimate incorporation of air 
with the sputa in certain aflfections of the lung; and it appears to 
me that we can scarcely understand this, unless we suppose that 
the air and mucus are secreted together. You are aware that air 
is secreted by the bronchial mucous membrane, and that in some 



INFLUENZA. 425 

cases this secretion is morbidly increased, in otiiers morbidly dimi- 
nished. Now, it is not very unreasonable to suppose that the 
mucous membrane may secrete air and mucus 'together in abnor- 
mal quantity ; and that this, rather than any mechanical agitation, 
may be the cause of the intimate combination of air with the expec- 
torated fluids. 

I need scarcely make any observation on the cough in influenza. 
It is in general very troublesome, particularly at night. Many 
persons are not much annoyed by it during the day, but at night it 
becomes very harassing, and prevents them from sleeping. When 
severe, it continues both night and day ; and even when persons 
have recovered from the fever and dyspnoea, and are able to go 
about, the cough will continue extremely troublesome : this I have 
observed in the majority of cases. In this state medicines prove of 
very little service, and one of the best remedies is to change to a 
mild country air. Cases of cough, in which I had tried every 
remedy without success, and which had resisted every form of 
treatment in the city, yielded in a few days to the salubrious influ- 
ence of change of air. 

In influenza, the urine is generally much loaded with lithates and 
super-lithates, and contains a large quantity of erylhric or purpuric 
acid. It is red when voided, deposits a good deal of sediment, and 
tinges the vessel in which it lies with a pink film. It bears some 
resemblance to the urine which accompanies arthritic and gouty 
afl^ections. In very bad cases, this state of the urine continues up 
to the period of death. You recollect what I stated with regard 
to the condition of the blood; it is generally bufl^ed, even where 
there is scarcely any febrile excitement in the system, and thus 
aflx)rds a very fallacious indication. The same observation holds 
good with respect to the state of the urine and the temperature of 
the skin. I may observe here that the heat of skin is very variable : 
it is sometimes very high, sometimes natural; in fact, like the pulse, 
it falls and rises in a very remarkable manner, at certain times in 
the day. 

I have already spoken of the affection of the mucous membrane 
of the bowels. I may observe, that in som.e cases of influenza the 
morbid influence is translated to the brain, and symptoms of deli- 
rium or coma supervene. Thus, in- two instances communicated 
to me by the surgeon-general, the patients fell into a state resem- 
bling coma, during the course of the disease. In three cases wit- 
nessed by Mr. Swift, the attack of influenza terminated in a train 
of symptoms bearing a close analogy to delirium tremens, and 
requiring the use of blisters to the head and nucha, full doses of 
opium, purgative enemata, wine, and the occasional use of mercu- 
rials. The patients complained of great headache, noise in the 
ears, some intolerance of light, and more or less sleeplessness from 
the commencement, along with the usual pulmonary symptoms. 
After five or six days, they became excessively nervous, lost all 
sleep, had continued subsultus and tremors, and talked, very ince- 

36* 



426 GRAVES'S CLINICAL LECTURES. 

herently, particularly at night. During the prevalence of the cere- 
bral symptoms, the pulmonary affection partially or wholly disap- 
peared, but returned again in some degree after the subsidence of 
the delirium. All these cases terminated favourably. 

I believe I have already remarked, that many persons who have 
laboured under very severe pulmonary symptoms will struggle 
through the disease ; and I may mention here that I have seen 
persons recover, who have suffered from continued orthopnoea for 
three weeks. Still the mortality, particularly among the aged, is 
very great; and I fear that we shall shortly have but few octoge- 
narians to tell the occurrences of the last century. Indeed, the 
mortality has not been confined exclusively to the aged, for many 
persons in the vigour of life have sunk under the attack. There 
have been several deaths among the soldiers in our garrisons not- 
withstanding the excellent state of health which our troops gene- 
rally enjoy, and the skilful and judicious treatment of our present 
army surgeons. The results of the medical treatment and necro- 
scopic observations in the different regiments in London, Dublin, 
and Edinburgh, will form a most valuable document, and I hope it 
will be made public for the benefit of the whole profession. 

It now remains for me to say a few words concerning treatment. 
First, as to bleeding. A great deal was expected from general 
bleeding, because the disease was sudden and violent in its onset, 
and accompanied by symptoms which seemed to require active 
measures — such as an inflammatory state of the bronchial mucous 
membrane, accompanied by quick pulse, hot skin, and high-coloured 
urine. This led persons to expect much benefit from venesection. 
The results, however, of its employment are, generally speaking, 
unsatisfactory. Where venesection was employed promptly and in 
the beginning of the disease, and where it seemed to be strongly 
indicated by the buffed and cupped state of the blood, even in such 
cases it has failed to afford anything like material or permanent 
benefit, or to produce a decided amelioration of the existing symp- 
toms. The general impression among practitioners in Dublin at 
present seems to be, that bleeding is doubtful in its effects, if not 
altogether improper. I am much inclined to think that bleeding, 
unless employed within the first twelve or twenty-four hours, will 
be likely to do as much or more harm than good. Bleeding on the 
second or third day, except to relieve congestion of the lungs, seems 
inadmissible. The same observation holds good with reference to 
other diseases. Thus, in scarlatina, if you happen to be called in 
when the rigor commences, and while the disease is beginning to 
form, you will often accomplish much good by bleeding your 
patient; but after eighteen or twenty-four hours, when the disease 
is fully formed, venesection will not do. On this point I can speak 
from experience. In scarlatina, the difference of a few hours ren- 
ders venesection inapplicable, and even injurious. It is the same 
thing with respect to influenza; general bleeding is useful only in 
the commencement, and, where the symptoms seem to demand it, 



INFLUENZA. 427 

it should be employed at least within the first twenty-four hours. 
Where I have been forlunaie enough to find the disease just com- 
mencing, I bleed to the amount of twelve or fourteen ounces, order 
the patient to remain in bed and take some aperient, followed by 
the use of nitre. In this way, by timely bleeding, aperients, sudo- 
rifics, and confinement to bed, the attack generally passes over in 
two or three days. I could mention many instances of the success 
of this plan of treatment. In one family I treated all the indivi- 
duals attacked in this way, and I have done the same thing in 
many cases of persons somewhat advanced in life. In the case of 
an old gentleman, who was very severely attacked, I succeeded by 
these means in checking the disease at once. My experience, there- 
fore, is, that bleeding is of service in the very commencement of 
the disease; but as it seldom happens that a physician is called in 
at this period, I would qualify my statement by saying, that, as a 
general measure, bleeding in influenza is seldom admissible. When 
you are called on to attend cases, you will most generally find that 
the patients have been ill for two or three days or more; and then 
the only mode of abstracting blood, which you can have recourse 
to with safety, is by leeching. About eight or ten leeches applied 
over the hollow of the neck, just above the sternum, and allowed 
to bleed pretty freely, will prove very serviceable; and if you apply 
them in the evening, you will often secure to your patient a good 
night's rest. This plan of leeching the hollow of the neck, in 
cases of tracheo-bronchial inflammation, is an excellent one : the 
leeches are applied at a spot which lies close to the trachea, and 
particularly to that point to which the irritation accompanying 
bronchilic afl^ections is chiefly referred. 

By the aid of leeching, the use of aperients, if necessa|-y, and 
confinement to bed, with sudorifics, you will frequently succeed in 
removing the fever and bronchial inflammation. You will derive 
much benefit, particularly in the early stage of influenza, from tar- 
tar emetic and nitre ; but I must say, that neither leeching nor 
tartar emetic and nitre prove as valuable .and as efficacious, in 
influenza, as they do in ordinary bronchitis. Some of my friends 
who used tartar emetic as a nauseant in the commencement of the 
disease, inform me that they have derived benefit from its use ; 
and others have told me that they have used tartar emetic and 
opium in the commencement and during the course of the disease, 
with advantage. I have not employed the first of these, but I have 
the latter, and with favourable results. You may, therefore, after 
using antiphlogistics for a day or two, proceed to the use of opiates 
in combination with tartar emetic or nitre. In some cases, the 
camphorated tincture of opium will answer very well; in others, 
you will find the acetate or muriate of morphia better. A mixture 
composed of six ounces of almond emulsion, a dram of nitre, and 
half a dram or more of the liquor muriatis morphige, will be found 
very useful. The muriate of morphia, which possesses many of 
the valuable properties of opium without its defects, will serve to 
tranquillise the system and produce sleep — two most important 



428 GRAVES'S CLINICAL LECTURES. 

points in a disease like influenza connected with increased nervous 
irritability. A gentleman, on whom I place much reliance, tells 
me that he has treated many bad cases successfully with camphor 
mixture, tincture of opium, and tartar emetic. I need not mention 
the various remedies which have been recommended in this dis- 
ease — as Mindererus' spirit, Hoffman's anodyne, ipecacuanha, alone 
or combined with extract of conium and blue pill, and many other 
remedies belonging to the class of diaphoretics or expectorants. 
They are all more or less serviceable, but they have all the common 
defect of producing less relief than they usually do in cases where 
the pulmonary affection is simple and idiopathic. Towards the end 
of the disease, you find it necessary to give stimulant expectorants 
and light tonics — as decoction of polygala senega, infusion of 
calumba, &c., &c.* 

One word about blisters, before I conclude. They are useful in 
some cases, but in many of the severe ones they do little or no 
good, and only add to the patient's sufferings. They do not relieve 
the pulmonary symptoms, and particularly the dyspnoea, in the 
manner you would be prepared to expect. I do not know a more 
remarkable circumstance, in the present disease, than the failure of 
bHsters ; and in many cases I do not employ them at all. Foment- 
ing the trachea and chest with very hot water appears to be much 
more serviceable. This has proved extremely valuable in many 
cases of this as well as other affections of the air-passages ; and on 
referring to the late American journals, I find that the plan of treat- 
ing croup in its onset, by means of very hot water applied with a 
sponge to the throat — a plan which I recommended some time ago 
in the Dublin Medical Journal — has been extensively employed in 
America, and with the most happy results. Sponging the throat 
and chest with water, as hot as it can be borne, has been found, in 
many instances, capable of arresting all the threatening symptoms 
of croup at once. Several cases are mentioned in the American 
journals, in which the lives of the little patients were evidently 
saved by this application. I may state, also, that not long since a 
child was saved in Dublin by the same means. By the advice of 
Mr. Smyly, who suspected the threatened attack, the child's mother 
had everything prepared, and by her promptitude and care arrested 
the disease before it had sulficient time to form. 

I have nothing more at present to add on the subject of influ- 
enza ; we are still much in the dark as to the best mode of giving 
relief — and this is the more singular, as in general the disease 
allows full time for the trial and operation of medical agents. 

* Doctor Blakiston strongly recommends the etlierial tincture of lobelia, 
in large doses, repeated at short iniervals, in inflaenza where bronchitis was 
present. As I had not the advantage of perusing his book during the preva- 
lence of the epidemic, (it was not published till May,) I had no opportunity 
of trying this medicine in the way he suggests. 



CLINICAL LECTURES, 



DEtlYERED AT THE PHILADErPHTA MEDICAL INSTITUTE AlfD AT THE PHILADELPHIA 
HOSPITAL (bLOCKLET), 



BY W. W. GERHARD, M.D. 



CLINICAL LECTURES. 



LECTURE I. 



Acute articular rheumatism — Connection with inflammation of the cardiac mem^ 
branes. — Treatment, bleeding, opiates, &c. 

I SHALL to-day, gentlemen, take np the subject of acute articular 
rheumatisnfi, as it is especially prevalent at this season of the year, 
when the number of other acute diseases is very limited. In summer 
we have acute abdominal inflammations, and in winter affections of 
the pulmonary organs, while, during the spring and early summer 
months, serous inflammations, both of the internal and external 
membranes, are most common. Acute rheumatism bears some 
striking relations with the inflammations of internal serous mem- 
branes, from the similarity of the mode of treatment which often 
becomes necessary in both affections, and from the frequent com- 
plication of the latter with the former disease. In almost every 
severe case of rheumatism under notice, there co-exists inflamma- 
tion of the covering of the heart, or of the serous membrane lining 
its cavities. Since this connection between the pathology of arti- 
cular rheumatism and that of diseases of the heart and its mem- 
branes, has been clearly traced, the disease has attracted much 
interest. I say clearly traced, for the general fact had been long 
since pointed out, although the subject was not precisely understood. 
That is, it was in the same situation as many other parts of patho- 
logy; affording an indistinct view of the truth, but without that 
well defined character which is now required, according to the 
rules of rigid logic which we endeavour to apply to the study of 
pathology. The line of connection has only been drawn in a de- 
finite manner, for a few years past, betu^een acute articular rheu- 
matism, and endocarditis, or inflammation of the lining membrane 
of the cavities of the heart, and pericarditis, or inflammation of the 
membrane surrounding it. Dr. Bouillaud, of Paris, has paid parti- 
cular attention to this subject ; he tells us that at least one-!ialf the 
acute articular rheumatic affections are complicated with pericar- 
ditis. In this estimate he is probably wrong, unless with pericar- 
ditis we are permitted to include endocarditis. A large number of 
mild cases doubtless run their course, without any complication of 



432 GERHARD'S CLINICAL LECTURES. 

the kind, but it is usually otherwise when the disease appears UDder 
a severe type, and we might say that many more than half the 
severe cases, probably two-thirds, are complieated with some in- 
flammation of the heart. Of the other third, a large portion present 
signs of some functional disturbance, though not of positive inflam- 
mation. Mild cases are slow in their action upon the heart, but, 
in the severer forms, the advance is rapid, and disease of the heart 
succeeds almost immediately after the first appearance of the arti- 
cular symptoms. In chronic cases, the progress of the cardiac 
affections is slow, and an individual not well acquainted with the 
disease might be deceived as to their existence. 

We have thus traced two forms of tlie disease, and I propose 
bringing under your notice two cases now ujader treatment in the 
Philadelphia Hospital, to exemplify them. 

The first is that of John Robb, who was admitted into ibe ware. 
No. 2, on the 11th of April. Previous to bis admission, he had 
been ill but a short time ; being an inmate of the Aims-House, he 
was able to resort to medical assistance quite as soon as is usaai 
in private practice. He had been working on the farm of the es- 
tablishment for eight months previous to his attack, and had 
enjoyed good health. On the morning of the sixth, he complained 
of slight pains in his shoulder, but continued at work; at elevcL. 
p. M., he was taken with severe pain in the hip, which lasted four 
or five hours, and then, diminishing in the hip, went to the kuee. 
On the seventh it ceased in the right knee and attacked the left. 

Now from the character of the affection, thus shown, we can, 
without going farther, make our diagnosis. I allude to its metas- 
tatic character, as exhibited in its leaving one joint and sellliog in 
another. This is almost distinctive of rheumatism. 

There was no pain in the ankles, but there was slight pain near 
the toe. You here mark the course of the disease onwards ; it has 
reached the toe, and shows a disposition to attack the whole foot. 
There had been pain in the right wrist, from an hour before the 
man's entrance into the hospital. On the ninth and tenth, he had 
pain in the breast, which he referred to a spot below the pr^cordia, 
in the region of the diaphragm, and which lasted tweuty-four hours, 
and was increased by coughing. Such pain is usually owing to 
disease of the heart, which may be merely muscular, but it is more 
frequently caused by inflammation of the serous membrane Uoii^ 
or covering the heart. 

This man had been exposed to no causes of disease other than 
those which he was in the habit of encountering. He had, il is 
true, been wet while working on the farm, but this was not unc^MU- 
mon with him : he had been long accustomed to working in the 
rain. This shows how cautious we should be in admitting causes 
of disease; some physicians might be disposed to attribute the 
attack of rheumatism to the last wetting, which could manifestly 
exercise do greater influence upon the man than a series of previa 
ous exposures to the same cause, of no recent occurrence. I look 



ACUTE RHEUMATISM. 433 

upon the particular season of the year as the principal excitant of 
the disease, and it is for this reason that I have thought it a fitting 
subject to bring before you at the opening of my course. If you 
take the trouble to inquire, you will find that at this time the pre- 
valence of rheumatism and rheumatic pains is remarkable. But an 
accidental exposure will often develope what might otherwise have 
remained dormant, and thus the disease, like many others, must be 
referred to two different causes, a general and an accidental one. 
The influence of the former is in this case much greater than that 
of the latter. 

The case before you being of an acute character, its previous 
history is not nearly so important as the present state of the indi- 
vidual. It is otherwise in chronic afl?ections, in which the whole 
anterior history is all-important. 

The condition of the patient at the time of his admission on the 
eleventh, was as follows. The face was slightly flushed, and pre- 
sented an expression of pain. This pain, in acute rheumatism, is 
remarkable ; it usually prevents all exercise and confines the patient 
to bed. 

There was slight soreness in the shoulder, but without swelling 
or heat ; no pain or swelling in the left arm, slight soreness in the 
right elbow, and severe pain, swelling, and heat in the wrist. The 
same pain, swelling, and heat extended to all the joints of the hand 
and fingers, excepting the thumb. There was some pain in both 
knees, especially in the left ; none in the ankles ; a little in the right 
hip, no tenderness of the spine, no cephalalgia ; tenderness on 
pressure along the region of the ribs ; this was probably the remains 
of the diaphragmatic pleurisy. The impulse of the heart was 
feeble, the second sound nearly lost, the first much roughened, 
dulness on percussion nearly natural. Treatment, one grain of 
opium every four hours. The digestive organs were healthy. 

Now, let us analyze this case. The first fact worth recollecting 
is the absence of tenderness of the spine. This establishes the dia- 
gnosis between simple rheumatism and that which is allied to neu- 
ralgia. Hence, the mode of treatment which proves so excellent 
in the latter aflfection may here fail. The state of the heart 
indicated merely slight valvular disease, and some muscular im- 
pediment ; there was no eflljsion, the dulness on purcussion being 
natural, and no creaking sound being heard. 

The treatment in this case was after a plan of practice in New- 
England, from which quarter it has been lately strongly recom- 
mended ; the internal administration of opiates, pushed till felt by 
the pal lent. 

During the twelfth, six-grain pills of opium were exhibited, but 
there was no diminution of pain. Neither sleep nor cephalalgia 
had been induced by the opium. This is an important therapeutic 
point, demonstrating the antagonising action which pain exerts in 
regard to the effects of opium. The first sound of the heart was 
still rough, but the impulse rather less ; no increase of flatness. 

37 



4M GEBHAED'S CLDflCAL LECTURES. 

The state of the heart was, therefore, slightly improved. Pulse 
eighty-foar, of moderate size and regular : a grain of opium was 
ordered every two hoars, and a laxative enema administered. 

On the evening of this day there was some cephalalgia, although 
no deviation of the pupils from the natural state. The dose of opium 
was diminished to a grain every three hours. Sleep was intermpted 
by twinges of pain ; sweating at nighL Eruption of sadsmma. : 
pulse seventy-two ; pain in right arm increased and extending to 
the shoulder. Less pain and swelling in the knees, but increase of 
both in the feet. The action of the heart was more regular and 
feeble, and the sound less rough. The disease, you perceive, was 
not in any manner arrested, although you note a decided improve- 
ment in the condition of the heart. There was costiveness from the 
opium, but this, you will soon see, disappeared. Same prescription 
of opium continued during the thirteenth : hop poultices to most of 
the painful joints ; laxative enema. 

On the fourteenth, the pain having diminished throughout the 
right arm, began in the left hand and wrist. Here is another point 
of interest : the translation of the pain from the right to the left 
limb by metastasis. This is a common thing in articular rheuma- 
tism, and, as in this case, the pain does not usually quite cease in 
one joint before it begins in the other. 

There was slight pain between the shoulders, and diminution of 
the pain in the knees and feet : pulse seventy -six, fuller and regular: 
this is somewhat an exception to its usual condition in the disease, 
it being generally frequent, small, and. tense. Skin warm and dry; 
sleep very irregular : tongue moist, with a yellowish coat : appetite 
bad ; thirst ; three or four stools since the enema : the opium had, 
therefore, induced no costiveness. 'So cephalalgia or dizziness : 
slight flush; eyes natural. Opium continued, hop poultice and 
laudanum to the left wrist. 

On the fifteenth, the left hand was worse, and there was pain in 
the sole of the right foot. The other pains were better, moisture 
rather than sweating. Opium continued. 

The sixteenth, less expression of pain, and less flush : soreness in 
both shoulders, with slight swelling, but not much constant pain. 
Shght soreness of the left elbow: much swelling, pain, and heat of 
the left hand ; right hand nearly free from swelling, still slightly 
painful, but motion returned : pains much diminished in the legs ; 
pain at the ensiform cartilage ; palpitations frequent after slight 
exertions; pulse seventy-two, and soft: decided roughness, almost 
xasping, in the first sound of the heart, which was not very loud, 
and heard most distinctly to the left of the nipple, second sound 
nearly lost Under the sternum, both sounds of the right side dis- 
tinctly heard and clear, the first only a little roughened. The 
prsECordial dulness commenced only at the left margin of the ster- 
num, and exteoded to the nipple. The morbid alteration was, 
therefore, confined to the left side of the heart, implicating the 
ralves; there was besides effusion into the pericardium. The opium 



ACUTE RHEUMATISM. 435 

pills were continued during yesterday and last night every three 
hours. Hop poultices. 

Last night the pupils were somewhat contracted, and little sensi- 
ble to the light. To-day the face was flushed, and presented an 
expression of stupor. Disposition to sleep; pupils rather large; no 
cephalalgia ; sleep interrupted by pain, shooting from the swollen 
joints. Pulse eighty-eight — softer. Swelling less marked in the 
left hand. Slight swelling and pain in both knees. No pain in the 
breast. Impulse of the heart almost lost ; both sounds very feeble, 
without rouGjhness. The disease of the valves is therefore dimi- 
nished. Percussion slightly dull at the upper portion of the left 
side; flat, down from the third rib to the same extent as yesterday. 
Prominence obviously increased. These latter signs are explained 
by the increased effusion into the pericardium. Still slight diarrhoea ; 
three or four stools in the twenty-four hours. Skin moist, without 
sweating. A grain of opium every four hours. 

This case, gentlemen, of acute disease of the heart, occurring 
in the course and as a direct consequence of acute articular rheu- 
matism, may serve as a type of the affection, which I shall now 
make the subject of some general remarks, and have occasion to 
refer to hereafter. There are several peculiarities to be alluded to. 
In the first place, the changeable character of the affection, shifting, 
as you have seen it, from joint to joint, denotes the nature of the 
disease. This is well understood, and universally admitted. But I 
would have you remark, that there was no metastasis to the heart. 
The disease of the heart appeared, during the most acute stage of 
the rheumatic fever, which afterwards continued with unabated 
severity. This is almost always the case: cases of metastasis are 
quite exceptional, and the cardiac inflammation is not only most 
frequent but is also most severe during the height of the articular 
inflammation. By physical examination, we ascertained that the 
pain in the praecordial region proceeded, first, from disease of the 
valves, indicated by the roughness of the sound ; secondly, from 
efl^'usion, shown by the unnatural dulness on percussion, imperfect 
action of the heart, &c. 

Another symptom to be noticed is the sweating, which was very 
slight from the first or second day, although it is generally very 
profuse in acute rheumatism. It is this sweating in rheumatism 
which has suggested the employment of Dover's powder, and other 
sudorifics, in its treatment. In this case opium was alone resorted 
to, to afford a better test of the powers of the remedy. 

The diarrhoea is another feature worth remarking, co-existing, as 
it did, with the large doses of opium. It was a purely accidental 
complication, but its occurrence demonstrates that opium, in very 
large doses, continued for some time, and given much in the same 
way as the large doses of tartar emetic are by the contra-stimu- 
lants, does not produce the same eflfects as in ordinary doses, thus 
illustrating a therapeutic law, that remedies, in over-doses, do not 
act upon the system in the same manner as when administered in the 



Qsoal qoadbSies. Were il 
the ai^uMi of 

be 

in Urn ^asfemsGE of 

The pat: , 
obscure ^-"' 
of ibe : 
of liae uerr . 
tkNi, are pc 
lo^om to lb: 



fiirlkBfaiw 




Forllaeppe: 

<af diemnii. 




i.!H'.w.Mlij| il K^ Bi liiis 

Tie oAer dJueaiffaR. Wq are abo 
"EliTe ineaas lor mrre^^m^ tie 

i^T^ieiy iato lie paibology 

id paildjras 

; tterareac- 







DaDTiQE inlernaT infiamn 



7i3ore ibc : : 
-iiiDod of li^a.1: 



lor 5 f 

sacztLi 

piaclici 

laeeasc 

every c 

idaafit; 

was QL. 



ACUTE RHEUMATISxM. 437 

lially relieved, while the rheumatic affection of the muscular sub- 
stance of the heart often increased. Besides, the ulterior results of 
excessive hloodletting are generally mischievous. We thus merely 
return to the old practice of one or two bleedings at the commence- 
ment of the affection ; a practice, the utility of which is sanctioned 
by long experience. 

Another practice, originating, I believe, in New England, and 
recommended by Dr. Webb, of Providence, is that which has been 
followed in the present case — consisting in the administration of 
very large doses of opium. I have tried it in two cases, in both of 
which it failed. It succeeded in stupifying the patient, and rendered 
him less sensible of pain, but produced no decided impression on the 
disease. It did not prevent the change of place, nor did it remove 
the pain or swehing. These symptoms persisted, and retained their 
usual mutability of character. Last summer, I pushed the remedy 
to such an extent as to induce decided narcotism, yet I failed to 
cut short the disease. The remedy may occasionally obtain the 
success which is claimed for it, but it is clearly no specific. 

Sudorifics constitute the treatment adopted by some, from a notion 
that artificial sweating is but an imitation of the curative process 
of nature. This is certainly not the case ; for the sweating is often 
profuse, while the violence of the disease is persisting. If, however, 
the discharge be suppressed, from cold or any other cause, it will 
be proper to resort to sudorifics, to revive this natural secretion, and 
restore to the patient what he has been deprived of; for in such 
cases the suppression of sweat is certainly productive of harm, and 
increases the suffering of the patient. 

Other remedies have been recommended, as narcotics and pur- 
gatives, particularly the colchicum, and, what is analogous to it, 
the veratria. The colchicum is used in this country and in Eng- 
land, but is not much employed in France. It is very useful as a 
palliative, though far from being absolutely curative. I have seen 
it stop the severer symptoms of the disease, for as much as five or 
six successive days, without curing the disorder. I often use it at 
the hospital without other medicines, preferring, as I do, the ad- 
ministration of simple remedies, particularly in hospital practice, to 
insure their accuracy of administration, and to enable us to judge 
of their eflfects. By giving the wine of the roots or seeds, alone, 
we may avoid the severe purgation resulting from Scudamore's 
mixture; but purging maybe of service, if the patient can readily bear 
the motion necessary for the evacuation of the bowels. But the dis- 
advantage attending frequent rising is apt to more than destroy the 
good arising from the revulsive effects of the purging. In medicine, 
as well as in surgery, inffamed parts must be kept at rest. 

In general, however, it is better to combine the colchicum with 
some opiate, as laudanum or black drop ; in doses of half a drachm 
of the wine of the seeds, or even more if tolerated by the patient, 
and ten to twenty drops of laudanum every two, three, or four 
hours. The preparations of colchicum are so irregular in strength 

37* 



i ■ 

iSS liHiiaEfflilgBns CMEMOl. lilSCrCBBSL 



iH e loy dOncait to 

s tttmi Mi c!!! ani Ibowdb bs ite bat ^ 

Una a ilDe dmte loff soqpliicisai n idb8iia& to ike 

gen wcffl €£ tibensBelveg^ ufae^ aav aqsa to ulecK^vie c^ 
cf ttlie resD&iiiies csaffltf^vd m weima^ tdbem. lU. 
case mik^ Dis. BoaiibiDd and WebibL For ttftie 
fegMCg* ^sff aheag gsBiiw»ioMiS cm ttihis sanftgrytf., I refeg* vc 
M<eflfedlObraByfl«37);s»diibrDr.W^ ^ 

I aa not dOqBiiBsdl to eiffiariiaoa liOtoiy «f I 
^ iSaxataUBta vibiidkkaw Sseea mecsoaBaHaBdfec 
csienaal apgsibcafiafias, ca^ to tdbe^nee^as^ 

ainnsss. oif fltoaaBti^sBL fiuA Tvfcra tte jsoalis : 
«f tdbe jfegasip, n wiafiit caftsesmidb b bdH to t^ 
«xr todbn to doe a^fone; aaoe^ tio IsdDker near it: : 
to idbe pasts wse iffirectedl Sar llie be. 
Fazxr llilii» pnpasBe^ amljae praiAtaoef 
#ffiB coie «iir hqpsi;, stopped IB boft waiter, c ~ 
alaafle fawfaawm. Tbeae ar^ 

i&scttwHBS aDO^ be loe^* smdk as a nii]^^ 
I ird&an §mm leaiil-waler, or ^panttwMB^ mr 
B tte tftanger ^ ibe iatteaaofl afe: 
ffis susoBewbat iBcveaseii b^tidvki^ 
[Ira pnitaac^aniat be i^E8srv«J i^ 

Olftier Ikaeal sqpf)£caaiafiia^ 
to^ sodk as abe cifieaiiQiioe tsf «vay gHafcaiiic . 
Hbe JBibv^ dhere anie <cflber Bcawtf^jfat;, abe vErtne.' 
citoBbA,aMdh{»tdfaega«BabdfefeaDig;,araaE^ 

ifiBTtdbem. TSmBwaaft of smooess wajideipciiii : 
«afy in tdfae ii>y ^laii^ oa wb»cb sbenr iMae« i 
caiUBctt be&sni« abat ttSos k "' 

oorno^ oifae : 



aa«e aN» afH to ffiin^naie wdb ad, aad to cio: 
tdatt we Bxeelt &saiil amy pSaja tctf t&Rsamss): 
liivMs wMt&K^ icfver WL I buve SbeBiefc ^ - 
i&s nibs Hsfilt m^lb^idki has beaa ateoiBoaaae: 
ii£cdi3Ci&. IctCBltaiifypelbediBltas '^ 
wamzanttai m ^vat^ awns iAbb «nie z 



ACUTE RHEUMATISM. 439 

larly as I could not see the patient after each dose, a precaution 
^vhich is always advisable when giving high doses of opium. 

In other cases of the disease, I am willing to try other modes of 
treatment which are highly recommended, although 1 fear that they 
are all merely palliative, and as such only may do good ; at last, 
we may find some one more etHcacious than the others. I am 
doubtful as to the immediate success, though strong in hope. I 
cannot help agreeing with Chomel, sceptical as he is generally, in 
believing inflammatory rheumatism an afiection not to be cut short 
by remedies, after having seen so much protracted suffering from 
it ; even in the case of physicians themselves, treated under the most 
favourable circumstances, it has been prolonged to four or five 
weeks and upwards. 

What is the natural duration of acute rheumatism ? It is not 
precisely fixed, but is scarcely ever less than two weeks, and may 
last for five or six months; at least, the immediate effects may con- 
tinue so long. Like most diseases that run a determined course, 
it averages two or three weeks. 

Although I do not believe that in most cases it can be suddenly 
cut short after the pain and swelling of the joints are considerable, 
yet an appropriate treatment is us(4ul as a palliative, and diminishes 
the mischievous results. In a few words, the treatment which I 
would recommend consists in one or two general bleedings, opiates 
combined \vith tartarized antimony or colchicum, and if the pain be 
very severe, local depletion is useful for those joints which are nearly 
in the state of ordinary acute or chronic inflammation. Purging 
and other remedies are directed when specially indicated. This 
of course is a mere outline of treatment, which requires frequent 
modification. 

Of the second patient whom I mentioned, my time will allow 
me to say little or nothing. He offers signs of disease of the heart 
different from those of the last, chronic dilatation and slight hypertro- 
phy, without disease of the valves, the sounds not being at all rough- 
ened. There is effusion into the pericardium, indicated by increased 
dulness on percussion. Further details I reserve for another occa- 
sion. 



LECTURE II. 

Continuation of acute rheumatism. — Rulieola, or measles, in adults and children — 
Symptoms — Complications — Treatment. 

I WILL again call your attention to the case of the man Robb, who 
was under notice as the subject to acute articular rheumatism. The 
opiate practice had been carried out with decided but gradual im- 
provement. Yesterday, however, there was a return of the affec- 
tion, but under a much less severe type, marking the stage following 



44© GEEHAED^S CLTPQCAL iBCTLTJiS. 

ihe acn'te form of the disease, in "whicii the FrmpiomB are F^'eliiDr: 
and mere soreness, raiher ihan piiin or iieat. With ihe reappear- 
airce of ihe aflfection in this modified shape, the impulse of tiie heart, 
irtiicii iiad been iDcreasing, tas been for two dajs much dimin- 
Kfaed. There is at present an effusion of about a piDt of Jiquid into 
the pericardiDm. Tiie duhaess od percDBsioD is so maiiifesi as i" 
leave no doubt of this fact. Il is not from ttie simple presenne 
imuBual duiijesB,lhal we draw our conciiBsion. but because we ht -. 
seen this duln^s BOlablT increase, from daj Id day. since the r-: 
tiBDt has been raider inspection. A prominence of the ciie? 
the region of the ijean iias also appeared, in a marked m: : : ■ 
during tiiis time. Another proof oi the effusion is the absence of 
the impulse of the heart, which is next to nothing- Ton recolletfl 
the roughness of the two sounds of the heart, panicularix the nrsi: 
tfais rot, : : " : has gone on. In proportion, 

tiien. as . -ds secretion, have tiie signs 

of r rst ^v±a^: 7 fact, which exemplifes 

a gr : . : . rr, IF wo -jctmg. Of pericardilk 

the pnysicai signs are. marnir.the mcrease of prominence and dol- 
iffi^ wi-- -"•;'• p^^ss of the impulse of the heart, while endocarditis 
is to be ■ : . ^d br increased action of the organ, and the rough- 
ened Boau:. ::: : : that termed rasping. The 
Tihvsir.a] sii:: . particularly of pericarditk, 
- : ' . . jOL, bo much so. that, knowing 
- . 7 . : , . , - . to decieci tiiem. Tiie two di^ 
eases are not iitery, I nave loifl yvu, to exist togeiiier under an 
equally sfevere type. Tiie same thing is true of pleurisy and pneu- 
miHiia: tiiey may co-exist, but very ^vere pleursyand pneumonia 
do r* r - rr' f- If, for example, the pleurisy be aggravated, 
by . : tite lung it impedes iiie development of acute 
r at iaw of palholog}-, founded on the two cases I 
u will find generally to hold good. I shall here 
: V E.rks on the case of riieumaiism : trie opiate prac- 
^ - - :.-.:. id till yesterday, when it was modified by tne sui> 
nf a single dose of Dover's powder at night, in place of th^ 

I: is :: .ii thk cour^ of lectjures, gentlemen, to take 

r rses in succession, as they come before 

. preserrtni^, as far as possible, tiie natural 

-iTion^si iijeui. A very unusual affection in general 

^: . . :ice has lately claimed your arteniion. J mean ruIteoJa. 

To see ii perradim; epidemically tte? w^rds of adults is a pheno- 

menon which I have never before witnessed, and hardly expect 

again to observe : as it is a disease which usualy appears bnt once 

during Jife, and is generally confined Id childhood. During the last 

six w^eeks, however, there have been as many as ^^yven or eight 

cases in mj single service, and three dt four in liffi other wards. 

Mt Fsceiit taisQ were as followE: 



SYMPTOMS OF MEASLES. 441 

Morris, a man of nearly forty ; Perry, a lad of eighteen, and 
three others of nearly the same age. 

Previous to detailing the symptoms which characterise rubeola, 
I shall make a few remarks on its pathology. The pathology of 
measles, like that of other exanthematous affections, is to be divided 
into two parts, one comprising the morbid changes in the body, 
which are characteristic of and essential to the disease, the other 
being those which are merely accidental. The first are of course 
to be looked on as pathognomonic. 

The description of the affection given by Sydenham is so good, 
and agrees so accurately with its appearance at the present day, 
that I shall read it to you at length, and adopt it, in most particu- 
lars, in preference to modern accounts. It cannot be amended 
materially, except by examining the symptoms with the aid of the 
numerical method; a task which, at present, I am not able to 
undertake.* 

This excellent description of Sydenham's shows his powders of 
observation in favourable contrast with some of modern times. 
His general account of the disease holds good in the cases which 
we observed at the hospital. Thus, our symptoms of the first day, 
like his, were chilliness and cold shiverings. The second day we 
had the catarrhal symptoms, connected with coryza and the flow 
of tears, as described by Sydenham. This is the best sign to dis- 
tinguish measles in its incipient stage from other exanthemata. In 
this stage, the other exanthematous affections offer no mark by 
which they can be diagnosticated with any certainty. They have, 
at this time, numerous symptoms in common, including some be- 
longing to other febrile diseases. Thus, in scarlatina, the sore throat 
is by no means sufficiently characteristic, and small-pox may, at 
its commencement, be very readily mistaken for typhoid fever. 
Dr. Louis, who certainly is most accurately familiar with typhoid 
fever, has more than once mistaken for it the incubation of 
small-pox. 

The symptoms that follow, as the sick stomach, loss of appetite, 
slight cough, heaviness of the head and eyes, occur now just as 
they did in the time of Sydenham. The only irregularity in Syden- 
ham's description consists in the large red wheals, which have not, 
in our cases, made their appearance, nor have I often observed 
them. The swelling of the eyelids continues the same. The 
vomiting occurs particularly in children, and not in adults ; we did 
not notice it in these cases. Looseness of the bowels is the next 
symptom mentioned. This is not now a constant symptom in the 
early stages of measles, but, it is to be recollected, that the descrip- 
tive account of the disease by Sydenham has reference to an epi- 
demic which took place in 1670. The diarrhoea I set down as an 
accidental symptom, .and, as such, it probably complicated the 
epidemic of that year, just as it does in our time those of other 
seasons. 

* It was then read. 



Wc nBxt pass to his dsscriptioD of the eruptiDH, ^lict te T:iia- 
xacterises most accurateiy. We have it now bs ttKE. appearh^ 
£rst in tae form of red spots, resembling fiea-bites, wfa icii gradual iy 
coaisseeintD semicircuiar, cr^ceniic. and circuiar shapes, showii^ 
themselves first on the face, and spreading tiience over tiie rest oi 
the body. As tiieeniptioii increases, tiiere is a diminution of tiK 
DttiBr symptoms. The eruption is found in the mouth and throat, 
as Tvell as on tiie siiin. Jn tiie ca^ of negroes, it is of course 
detected only in liie eyes and throat. In tiie pharynx and paiaee, 
as elsewiiere, tiie eruption is not so much elevated above trie 
epitiielium, as it is above tiie surface of tiie skin. Trie nest part m 
the description is doubtful — tiiat is, tiie mode of disappearance n: 
tiie eruption. It does not totally disappear on tiie eighth or nintf. 
day. as alleged by Sydenham, for traces of it remain for some time 
afterw'^ards. m copper-coloured spots, as shown in tiie cases in our 
'wards ; even after tiie spots entirely disappear tiie siiin remains 
lougfa and dry. I do not at this time intend to go more largely 
into ttie ordmary symptoms of measles, for I can scarcely add any- 
thing tn tiie graphic description which 1 have read to yon from 
Sydenham. White at Paris, and at liie Hospital des iinfans Maia- 
des, I collected a mass of observations on this subject : but not yet 
iiaving i>een able to anai\:ze tiiem. I must deter presenting tiiem. to yon 
to some future time. I siiali now call your attention iv two of ttje 
accidental symptoms which may complicate the regular course of 
measles, and often become tiie sources of gisat danger. 

Tiie first is bronchitis of a severe ciiaracter. A slight bron- 
chitk may be looked upon as a nec^sary svmptom of tiffi disease r 
it is to i>e deemed accidental when it appears under an aggravated 
type, or wiien tiie iufiammatioi] runs into trie parenchyma of trie 
lungs, and takes od trie form of lobular pneiraionia, which is simi- 
lar to tiie pneumonia following the bronchitis of young children. 
This accidental symptom occurred in tiie man Morris, whom yon 
recollect in liie first ward, about tiie eighth or nmlh day, when 
tiie eruption was fading, and our attention wxis dinected to tlffi de- 
velopment of moist rhonchi on tiie right side of tiie ciesl. showing 
ttie existence of severe bronchitis, witn considerable duiness on tiie 
middle and posterior part, and some on tite anterior region of tiie 
iefi side — a common seat of lobular pneumonia in measles. 
Instead of getting well, tiie man has remained ill. exemphfying tiie 
general rule. that, wiien lobular pneumonia is developed, after tiie 
sutHiaence of tiie eruption, it lastsfora considerable tei^th of time. 
Tiie signs, by which its appearance is to i>e detected, are dulness 
on percussion, with a sut>crepitant rhonchus. and a slightly bron- 
chia] respiration. In piace of atiackiiir ine mass of the lung, and 
rendering it solid, the inflammation arrears m tiie isolated lobules, 
leaving amongst tiiem portions of the lun^r still pemisabie to tite 
air, which prevent liie development of loud bronchial respiration. 
Tne respiration, in tiie very early stages of tite disorder, and in tiie 
portion of the lungs which are no: mfiamed, is not lost, but rei>- 
dsred buder, and rouorhsned. 



MEASLES — COMPLICATIONS. 443 

In the case of the boy Perry, the pneumonia appeared on the 
eleventh day of the disease, after the eruption had entirely subsided, 
no traces of it being left but a few copper-coloured spots. His 
right lung was attacked, as is commonly the case; perhaps, from 
its greater size, and from the circumstances of the patient's lying 
upon the right side. The lower, and not the middle and upper 
lobes, was attached ; in this respect as well as in others, it is like 
ordinary pneumonia, but differs from it in the loudness and loose- 
ness of the crepitus, which ceases in regular inflammatory pneu- 
monia as soon as the entire substance of the lungs becomes 
solidified. In the boy's case, as in that of Morris, convalescence 
has been very slowly established, and is yet by no means perfect; 
he is still lingering in a somewhat critical condition, in the case of 
Morris, I entertained, for a time, some fear of the existence of 
tubercles, the development of which is thought to follow attacks of 
measles : I say, is thought, for I am by no means certain that there 
is any necessary connection between the two aflections. 

The treatment proper to meet this complication of measles is 
necessarily various. At the Hospital des Enfans Malades, during 
my residence, local depletion by cups and leeches was largely em- 
ployed by Dr. Guersent. But the debility, consequent on this mode 
of treatment, was favourable to the reproduction of the disease in 
other parts of the lungs, especially as the pneumonia was observed 
almost invariably in children of feeble constitution. The proper 
rule fortheemploymentof bleeding leeches, is to confine them to cases 
in which there is excessive dyspnoea, and a rapid extension of the 
pneumonia is going on. It extends through the lung most rapidly, 
in stout, robust children, and in ihem leeching does good. In the 
ordinary lobular pneumonia, as well as in that which follows 
measles, after one or two cuppings, the best treatfnent consists in 
small doses of ipecacuanha. By persevering with this remedy, 
until the expectoration, or rather the secretion, (for with children 
there is no expectoration, as they swallow the discharge,) is freer, 
the patient is relieved, and we may then complete the cure, by the 
exhibition of tonics and a generous diet. Above all, attention is to 
be directed to position. If the child lie constantly on its back, the 
development of pneumonia is almost certain. It must, therefore, 
be moved frequently from one side to the other, and be from time 
to time raised in bed or carried about. In addition to ipecacuunha 
in expectorant doses, the sulphate of quinine and some preparation 
of iron, in small quantities, may be given, combined with a gener- 
ous diet, if the child should become feeble, and the quantity of red 
blood should diminish. You will find, that in my lectures, gentle- 
men, I am not at all disposed to insist on too rigid a diet. I have 
seen so much mischief result from the continued enforcement of a 
rigid diet, in accordance with the mode of practice which was pre- 
valent in France a few years ago, that it is with great caution, and 
no little reluctance, that I venture upon it, except for a short period. 
In some of the wards of the Enfans Malades, the practice was to 



444 GEr.'d A . ^ -S CLDIICAL I.EC7riIBE& 

place the cbildreo on a rigid diet, and the resolts were certainly far 
from favourable. 

In the cases aoder qoiice, by pursuing the practice indicated, we 
have, in a great measure, succeeded in getting rid of the accidental 
symptoms. But there is still some cough, and other traces of tin- 
gering bronchitis. What is now the proper treatment ? It should 
be principally hygienic The patients are to go freely into the 
open air, taking internally, at the same time, some of the milder 
tonics. 

The next accidenial symptom, likely to complicate the course of 
measles, is severe diarrhoea, near to the cIos$e or after the termina- 
tion of the disease. At the Enfans Malades, the children died in 
two ways when measles proved fatal, of lobular pneumonia, during 
the active period of the auction, and of diarrhoea, at the end of it 
The lobular pneumonia usoally showed itself about the sixth day, 
the bronchitis appearing much earher ; but the diarrhoea does not 
usually come on until the eruption is almost over and desqua- 
mation was taking place. If this diarrhoea be but slight, no danger 
need be apprehended from it, and we rather avoid much interference 
with iL Indeed, it is generally looked upon as a safeguard to the 
child, and is, therefore, suffered to run on. But I do not consider 
the diarrhoea as sUght and not to be checked, if it exceed four, five, 
or six stools, during the day, and continue until it is accompanied 
by emaciation of the child, with paleness and dr3rness of skin. This 
variety of consecutive diarrhoea depends commonly upon a par- 
ticular state of the mucous membranes, in which they are pale and 
soft, seeming to be acted on by the altered fluids in the body, and 
instead of being themselves the seat of very active disease. I 
showed yon the other day, at an autopsy, a similar state of the 
mucous membrane, but occurring in the stomach ; in this case, 
however, it was probably product by the action of the fluids after 
death. This state of the mucous membranes, as it occurs in 
measles, I do not r^ard as an effect of inflammation, nor is it to 
be treated as such. Depletion, of any sort, here does no good, nor 
do remedies specially directed to the boweb always prove of much 
service. You must act on the skin until its functions are restored, 
and for this purpose nothing is better than the sulphur bath, made 
by dissolving the snlphnret of potassa in water. I have seen chil- 
dren recover, at the Enfans Malades, under this treatment with 
astonishing rapidity. It not only relieves the particular symptom 
to which it is addressed, but much improves the general condition 
of the patienL Indeed, it was remarked by Jadelot, that the same 
remedy, employed for the management of itch, not only cured that 
auction, but besides left the patient in a general state of health and 
embonpoint. If the sulphur bath cannot be administered, one of 
warm salt water may be substituted. In addition to this treatment, 
adapted to the skin, slight opiates may be resorted to, with small 
doses of ipecacuanha, and astringents, which are snppoi^ by some 
to act chemically upon the bowels. But depletion, by leeches or 



MEASLES — DIARRHOEA. 445 

cups, must be abstained from, and the diet should be nutritious, but 
of a nature to leave little residue for the colon. 

The last variety of accidental lesion, which occurs during measles, 
is acute diarrhoea during the height of the affection. This compli- 
cation I have not witnessed during the epidemic at the hospital, 
though it was a very frequent occurrence at the Enfans Malades, 
in 1832, which was just before the cessation of the Asiatic cholera 
at Paris. That epidemic of measles was probably similar in its 
character to one described by Sydenham. The disorder is de- 
pendent on acute inflammation of the colon, and shows itself at the 
most intense period of the eruption; it is attended, generally, with 
the usual symptoms of dysentery, considerable pain, stools small in 
quantity containing slime, sometimes patches of false membrane, 
and blood ; in fact, we have a regular attack of acute dysentery, 
complicating the measles. The complication is, I believe, most apt 
to occur in the summer months of the year. That is, measles are 
subject to the general rule of pathology, which determines the nature 
of the accidental symptoms, attending self-limited diseases. Thus, 
in the typhus fever, which was epidemic here during 1836, and 
part of 1837, we had, during the winter, symptoms of the acute 
affections most usual in winter, as those of the chest, and, in summer, 
it was complicated with diseases which are endemic in hot weather, 
as dysentery and disorders of the alimentary canal. Neither of 
these accidental affections was in any manner a necessary accom- 
paniment to the typhus. The complications of measles follow the 
same rule, except that, both the inflammations of the lungs and the 
bowels are more frequent than in typhus fever ; we have, in other 
words, very generally lobular pneumonia occurring in the measles 
of winter and early spring, and affections of the alimentary canal 
when the epidemic takes place in the summer months, particularl}'' 
July and August. 

The post mortem appearances, in this affection, differ from those 
of ordinary diarrhoea. If closely examined, the colon and rectum 
are found to be covered with patches of lymph, and their mucous 
membrane is much disorganized, and of a violet tint, as in severe 
dysentery. So universal were these appearances on dissection, 
during the epidemic at the Enfans Malades, to which I have just 
alluded, that a gentleman, who was observing it, thought that he 
had discovered a new law of pathology, and that there was a con- 
stant connection between rubeola and inflammation of the colon. 
He was, however, mistaken, and from his error we may see the 
importance of observing with care the phenomena of several epi- 
demics, and of again and again repeating these observations, 
before we allow ourselves to make from them any general deduc- 
tions. 

The treatment at the Enfans Malades for the dysenteric symp- 
toms was the same that is employed in ordinary dysentery. It was 
attended with no great success, but it must be remembered that 
severe dysentery is at all limes a difficult affection to treat. The 

38 



446 GERHARD'S CLINICAL LECTURES. 

remedies, however, should certainly be the same when dysentery forms 
the complication of which we have been speaking as in the common 
variety where it is the primary disorder. In the early stage we must 
have recourse to antiphlogistics, used with some freedom, by leeches 
and cups to the region of the colon and the anus. The dysentery 
differs essentally, as I have before said, from the diarrhoea occurring 
at the close of measles, and we have no fears here about the propriety 
of an energetic antiphlogistic treatment; it affords prompt and great 
relief We may afterwards administer opiates in very small quan- 
tities, and moderate doses of ipecacuanha. Calomel is so rarely 
employed in France, that I never saw it prescribed in those 
cases, and have not been able to test its efficacy in this affection 
frequently enough to speak of the advantages of using it. The 
after management of the dysentery of measles is also much the same 
as of common dysentery, except that the former will be found to be 
of greater obstinacy than the latter usually is. 

From these details, then, we deduce the following corollary. In 
measles, as in other diseases of known duration, we have one con- 
stant set of symptoms, as the eruption, and febrile movement with 
anorexia, thirst, restlessness, &c. ; and next, a series of accidental 
symptoms, which extend from the slight bronchitis, necessary to 
the affection, to severe bronchitis and lobular pneumonia, and from 
the slight attendant diarrhoea, to diarrhoea of the sub-acute form, 
and severe inflammatory dysentery. It is to these accidental 
symptoms that you are to pay particular attention ; and by doing so, 
I am persuaded you will much diminish the mortality of measles, 
which depends, as in typhus fever and small-pox, mainly on the 
severity of the accidental complications. 

There remain to be noticed some varieties of measles, not observed 
here in the late epidemic. The first variety occurs in the other ex- 
anthemata, and consists in an imperfect development of the eruption. 
This is not so frequent in measles as in scarlatina; but we have 
occasionally coryza, a flow of water from the eyes, and cough, with 
but a very slight eruption, or one that is confined to the face. This 
is still a genuine, although an anomalous form of measles. 

The second variety consists in the severe complication of inter- 
nal inflammation with the eruption, w^hich disappears soon after the 
beginning of the disease, and may be looked upon as suppressed. 
You then have universal bronchitis, the whole mucous membrane 
being afl^ected with inflammation of an intense character, instead of 
the usual slight blush. We have then a grave internal affection, 
occasioned by the want of action on the surface of the body, the 
disease being, as it were, concentrated in the internal organs. This 
variety is always attended with great danger. It is to be treated by 
active counter-irritation of the skin, to supply the place of the absent 
eruption ; for this purpose, sinapisms., the warm bath, and the like 
rensedies are to be resorted to. 

The third variety is the black measles, or rubeola nigra. This is 
not a real variety. It occurs in feeble children, in whom the blood 
is in a dissolved state, as from scurvy ; or it may depend on the sudden 



SEROUS MEMBRANES. 447 

development of lobular pneumonia, preventing the proper decarbo- 
nizalion of the blood in the lungs, and giving it a general dark tint. 

These varieties are almost the only ones that you will meet with 
in practice, and on which it is therefore proper to dwell. Rubeola 
sine catarrho I have never seen — I scarcely believe in its existence. 
Some change in the bronchial mucous membrane is always to be 
detected ; there is a dry rhonchus indicating a thickening of it, or 
we have at least some traces of a moist secretion. Cough is not a 
necessary attendant upon a slight bronchitis, and it is impossible to 
decide with certainty upon its non-existence without a very careful 
examination, and I suspect it is the absence of close observation 
that has given rise to the variety of rubeola sine catarrho. 

I have presented to you to-day but few clinical illustrations, as 
I was desirous of giving you a somewhat detailed descriptive notice 
of measles, a disease of frequent occurrence, and which now 
prevails epidemically. J have insisted particularly upon the import- 
ance of the accidental symptoms which are most frequent, for 
although other organs, as the brain and the wind-pipe are sometimes 
the seat of grave lesions, they are not usually so much affected 
as the thoracic and abdominal viscera. There is another com- 
plication which is not rare in some epidemics, that is, the gan- 
grenous sore mouth of children, of which I shall treat at a future 
time. 

Measles is perhaps a more frequent cause of after ill health than 
any of the other exanthemata. The bad effects of small-pox and 
scarlatina are usually confined to the course of the disease; they 
destroy life at this period or soon after. But measles, though less 
dangerous during the eruption, may leave behind it greater organic 
lesions than either of the others. The effects of lobular pneumonia 
and diarrhoea are not easily got rid of; and, after a supposed con- 
valescence from measles, we but too often see our little patients 
wasting away from emaciation, and after a lapse of a few months, 
perishing from the consequence of one or other of these dangerous 
complications, or from tubercles in the lungs, the lymphatic glands, 
or the follicles of the intestines. 



LECTURE III. 

Inflammations of serous membranes — Pathological anatomy — General symptoms. — 
Pleurisy. — Tuberculous peritonitis, etc. 

In my lectures on pathological anatomy J have already pointed 
out to you the distinctive characters of the inflammations of the 
serous membranes. As you, no doubt, remember, these charac- 
ters consist in the bright arterial injection of the membrane, and 
the secretion into its cavity of lymph, serum and pus. The lymph 



448 GERHARD'S CLINICAL LECTURES. 

is secreted very early; I once detected it in a case of pneunciothorax 
whicii proved fatal in an hour after the perforation : at first it is 
secreted in the form of minute points scattered thickly over the 
inflamed surface ; as these points become more numerous, they 
gradually run together, until the whole surface is covered by a 
tolerably uniform coating of lymph, which is then called a false 
membrane. Portions of the lymph are afterwards detected in flakes 
interspersed through the serum. The liquid consists chiefly of serum, 
which is sHghtly turbid from the admixture of lymph, and of a 
small portion of pus, which gives it a yellowish tinge. The pus is 
not abundant in acute inflammations, and in subjects of a feeble 
constitution is scarcely perceptible; but when the inflammation 
becomes chronic the proportion of pus gradually becomes more 
considerable, until it at last forms the whole of the liquid. It is 
then called an empyema when formed in the pleura. 

The manner in which the gradual absorption of the liquid occurs, 
and the two surfaces of lymph become organized, and finally adhere 
together, must also have become so familiar to you as to require 
no further description at present. 

Serous inflammations may be either primary or secondary. 
When secondary, they are usually dependent, first, on the previous 
existence of inflammatory rheumatism, secondly, on disease of the 
organs which they invest, and thirdly, on the existence of a tuber- 
culous diathesis. I shall not now dwell upon the rheumatic causes 
of serous inflammation, as I entered into this subject, at a former 
lecture, when speaking of a case of acute articular rheumatism 
in which pericarditis occurred. Its connection, too, with disease 
of the parenchymatous tissues covered by serous membranes, we 
shall discuss at length, on some future occasion, when we may see 
that inflammation of the lungs, liver, that, in fact, every lesion of 
an organ, gives rise to more or less inflammation of its serous 
covering. This process is an effort of nature to isolate and protect 
the diseased organ. The third cause of serous inflammation, that 
is, the existence of a tubercular diathesis, is the most complicated, 
and presents the most numerous points for examination : into some 
of these we shall enter this afternoon. The connection between 
serous inflammation and tubercles is the more important, from its 
enabling us to recognise a number of tubercular cases, otherwise 
obscure, by reasoning upon the law of pathology, that tubercles are 
so often connected with inflammation of these membranes. 

In addition to those above mentioned, there may be other causes 
of secondary serous inflammation ; they may be mechanical, as 
perforations, outward violence by blows, and the like, and the influ- 
ence of cold which may be felt in the membrane surrounding the 
joints, intestines, lungs and heart, producing a primary inflammation. 

That secondary serous inflammationsare notof much more frequent 
occurrence than they are, is to me a matter of surprise, when I 
reflect upon the close connection of the organs with their serous 



SEROUS MEMBRANES. 449 

investment; at all events, they are cooiparatively of more import- 
ance than the primary forms, from their greater fatality. 

There are certain signs common to serous and other inflamma- 
tions, by which they are generally ushered in. These are chill, fever, 
and sweating, with a general malaise, or feeling of wretchedness, 
loss of appetite, thirst, and in fact the ordinary febrile symptoms. 
They may, however, be entirely absent, and I have seen patients 
die of acute peritonitis without either fever, thirst, or severe pain. 
The pain accompanying serous inflammation is usually sufficiently 
indicative of its character. It may be said to be specific, being 
lancinating, sharp, acute, resembling such as would be inflicted by 
the stab of a knife. It is ordinarily described by patients in these 
terms ; it may, however, be so slight as not to confine the patient 
to bed, in fact, not severe enough to enable him to localize the dis- 
ease. Patients often come into the ward, with the general febrile 
symptoms above mentioned, without local suffering enough to allow 
them to fix the particular seat of their disease. It is obvious, then, 
that we cannot trust to the character of pain, in determining the 
nature of the affection, but must resort to physical examination, the 
phenomena of which, resulting from the identity of the liquid se- 
creted, will be always the same. 

There is, besides, a disordered action of the organ invested 
by the serous membrane ; in pericarditis of the heart, in pleurisy, 
of the lungS; and in peritonitis, although not so distinctly marked 
as in other inflammations, there is generally sufficient evidence of 
disturbance in the action of the bowels. 

The state of the pulse is another sign, supposed to be especially 
characteristic of this disease. But you recollect that, in the case 
of the man Robb, the pulse was merely moderately frequent, seventy- 
six per minute, notwithstanding the pericardium was inflamed ; and, 
in another patient, labouring also under intense serous inflammation, 
you noticed also that it was very nearly of the same frequency, that 
is, decidedly not febrile. The character of the pulse is, therefore, 
a faithless sign of the existence of serous inflammation ; it may be 
peculiar, small, wiry, and of intense activity, in which case bleeding 
is demanded without delay ; but these distinctive features are not 
always present. 

In the patient noticed to-day, the pleurisy was nearly, though not 
entirely, latent. The woman, whose case was before you, had 
neither pain nor fever, although there was an eff'usion into the pleura 
of a quart and more in amount. The signs of this effiision were 
merely physical. This latent pleurisy is a common affection with 
old people, many of whom perish from it, when supposed to die 
simply from the decay of old age. In young persons these diseases 
are not so often latent, except in a very chronic form, or where the 
patient has been exhausted by previous illness. An example of this 
was furnished by the case that terminated yesterday fatally at the 
hospital. It occurred in a patient, who had been labouring under 
chronic peritonitis for a year previously, and who was taken about 

38* 



450 GERHARD'S CLINICAL LECTURES. 

a week since with a slight increase of his ordinary pain, accompa- 
nied by severe prostration, which carried him off in a few days. 
An exception to this rule, however, occurred at the Pennsylvania 
Hospital three years since in the case of a man who was run over 
upon the belly by a cart. He suffered but little pain, from the first 
day, and was afterwards suddenly carried oft', although the only 
alarming symptom was extreme exhaustion. Very extensive peri- 
tonitis existed, but without pain, although the intestines were covered 
with lymph. You see, therefore, how difficult it is to recognise the 
presence of serous inflammations, from the functional signs which 
are presented. If we had no other means of examination, or if we 
omitted physical exploration, because there were no special symp- 
toms to arrest and direct our attention, we should be constantly in 
error. For example, it is a very common occurrence with labour- 
ing men, sufl^ering from chronic eff'usions into the pleurae, to com- 
plain of pain, not in the region of the pleura, but lower down, in 
the flanks, whence they are sometimes treated merely for lumbago. 
In such cases, there is absolutely no rational symptom to indicate 
the nature of the disease and the proper mode of treatment; it is 
by the local signs only that the true character of the affection can 
be traced. 

The duration of serous inflammations is by no means fixed. It 
may be divided into two periods, the one including the time that 
passes during the increase of the effusion ; the other, that during its 
stationary and declining stage. After effusion has taken place, it 
is not possible to cure the patient abruptly; time is absolutely re- 
quired for the consolidation of the false membrane, and for the ab- 
sorption of the pus and serum that have been secreted. In all acute 
inflammations of serous membranes, if you see the case only after 
effusion has taken place, you may safely predict that your patient 
will not be well, at least, for several days ; and the rapidity of the 
recovery will depend upon the quantity of liquid which has been 
effused, and the time it has remained in the pleura. But, if you are 
called to a case, say of pleurisy, at the beginning of the attack, 
while there is merely slight inflammation without much effusion, the 
patient may get well abruptly, and the morbid secretion may be 
limited to a little lymph, which is a necessary consequence of all 
serous inflammations. 

I do not intend now to enter at length into the peculiarities of 
treatment, nor into a detail of the physical signs, belonging to the 
varieties of serous inflammations, except so far as they may be 
exemplified by the cases which I shall bring before your notice. 
The remarks which I have just now made were necessary in order 
to make clear a number of cases, the histories of which I shall pre- 
sently relate to you. You must bear in mind the distinction which 
I made between primary and secondary serous inflammations. The 
first of these is rarely fatal, except in the brain or heart; by interfer- 
ence, you may shorten its course, but you expect it to get well under 
any circumstances. Inflammationsof this character depend merely on 



PLEURISY. 451 

atmospheric vicissitudes or other such cause, and are not preceded 
by a tubercular lesion, or connected with this diathesis, nor are they 
the result of a perforation, which is generally irremediable. When 
you have a secondary serous inflammation, you are to look upon it 
in most cases as an eflx>rt of nature for the preservation of the 
part; and when it is complicated with inflammation of the paren- 
chyma of the organ which it invests, it is a curative and preserva- 
tive process, and is not to be interfered with, unless it is of that 
severe character which endangers the life of the patient. 

The first illustration, which 1 shall bring before you to-day, is the 
termination of the case of the man Robb. At the last lecture, I 
mentioned to you that the rheumatism was almost cured. The 
afl^ection of the heart was then, and is still, persisting, although it is 
now chiefly limited to the internal membrane of the heart, and the 
symptoms are still so severe as to prevent the man's yet leaving 
his bed — a proof of the difficulty of suddenly arresting diseases of 
this nature. These cases of serous inflammation, occurring during 
an attack of rheumatism, generally assume a character altogether 
independent of the course of the latter affection : the great fire goes 
out, but the smaller burns slowly on. Not only, indeed, does this 
cardiac inflammation run its course, but it often leaves behind it 
organic changes in the heart, that may last for a succession of 
years, or for life, in the form of thickening of the valves, or adhesion 
of the laminae of the pericardium. Numerous cases of extensive 
disease of the heart take their origin in an attack of rheumatism; 
they may, on the other hand, be of a slight character, and entail no 
greater disturbance of the economy than slight palpitations, and an 
inability to use the same amount of active exercise as in perfect 
health.* 

The next case I shall notice is somewhat curious ; it is pleurisy, 
occurring in a young Irishwoman, Isabella M'Gargee. In Decem- 
ber, 1837, she was exposed to great fatigue, and sufl^ered much 
mental anxiety during the illness of a relative; she was then taken 
ill with severe pain in the region of the heart, dyspnoea and palpita- 
tion ; for these symptoms she was bled and blistered with relief. 
Her health, however, was not entirely restored; there was still 
palpitation, at times cough and some oppression. At the beginning 
of April, she worked very hard in a damp cellar, washing clothes, 
and was seized, in a day or two afterwards, with fever and pain in 
the right side, extending from the breast towards the nipple, and 
much increased by respiration, or by the cough, which was short 

* This patient was perfectly cured by rest, some local depletion, and a blister : 
his care was absolute, for three years after he was engaged in very laborious 
work without the slightest disagreeable feeling about the heart, or any abnormal 
sound. In most cases I use depletion more freely, but from the general aspect 
of this case I was induced to resort to bleeding of any kind in a very moderate 
degree, and the result was extremely favourable. It should be remembered that 
there was little pain and no febrile excitement. These aflforded the chief reasons 
for abstaining from much active treatment. 



452 GERHARD'S CLINICAL LECTURES. 

and dry, not frequent. There was also pain caused by lying on 
the affected side, with considerable oppression. The gradual in- 
crease of these symptoms obliged the patient to enter the hospital. 
There was no oedema of tiie limbs, and but moderate palpitation; 
there was no important previous treatment, and the patient was not 
strictly confined to her bed. 

We now inquire if the disease can here be recognised at the first 
glance, from the detail of symptoms gathered from the patient. It 
cannot. Let us enter into an examination of the symptoms. In 
the first place, can the affection be neuralgia 1 It has some points 
of resemblance with this disease, but it differs from it in many 
particulars which are sufficiently well marked. First, it is not com- 
mon for any considerable degree of cough to exist in neuralgia, nor 
have we in it a steady, local pain, as in the case described. An- 
other set of symptoms, which establishes the difference between the 
two affections, is that belonging to the countenance, the medical 
physiognomy oi the case. This is characteristic, not of neuralgia, 
but of an intense pectoral disturbance. 

Satisfying ourselves that it is not neuralgia, we make a general 
diagnosis of an acute disease of the chest, first, from the severity 
ot the dyspnoea present, established by the spasmodic contraction 
of the chest and of the nostrils; and, secondly, by the alteration in 
the colour of the countenance, in tho dark blue tinge of the lips and 
flush of the cheeks. This is not purple enough for the existence of 
pneumonia, and we, therefore, infer, that our case is, probably, one 
of bronchitis, pleurisy, or acute phthisis. 

Having carried our examination thus far, let us proceed to dis- 
criminate between the affections, to which we have reduced the 
case. This can be done only by physical exploration, without 
v/hich it is impossible to recognise with absolute certainty the dis- 
tinctive features of the disease. What, then, are the physical signs 
which estabhsh the character of the affection belore usi First, we 
have an abnormal development of one side of the chest, at the lower 
part, and diminishing gradually in ascending. This, at once, settles 
satisfactorily the nature of the affection ; it is a pleurisy. Had the 
development been confined to the anterior part of the chest, it might 
have been emphysema, or, had it been local, pericarditis; but only 
a pleuritic effusion could have made it what it was. Next, we 
have immobility of the ribs: in the present case this could result 
only from pain, from distension, or from old adhesions. The his- 
tory of the case disproves the probability of the existence of old 
adhesions on the right side ; so that from the pain, then, we again 
deduce the presence of acute pleurisy. 

Continuing the examination, we next proceed to percussion, which 
yielded the following results. There was flatness in the lower pos- 
terior half of the side of the thorax, and of the lower third on the 
anterior part ; as well as of the lower half of the axilla. Thus far, 
■we can diagnosticate, with certainty, the existence of pleurisy ; the 
flatness followed the line of gravity, or, in other words, corresponded 



CASE OF PLEURISY — TREATMENT. 453 

with the situation of the Lquid, which, following the ordinary laws 
of liquids, accumulated in the bottom of the chest, just as if it had 
been contained in a common bag. 

We continued the examination by auscultation. Had the disease 
been pneumonia, we should have had bronchial respiration and a 
dry crepitus. This was not the case, as the lung was quite perme- 
able to the air, and not a hard, solid mass. There was no rhonchus, 
for there was no liquid in the bronchial tubes. The physical signs, 
then, have led us to a certain conclusion as to the nature of the 
affection. In many cases of pleurisy, when the lung is more con- 
densed, we have, however, a bronchial respiration, but no crepitus, 
unless complicated with pneumonia. 

The next question that presents itself is, as to the primary 
or consecutive character of the disease. To solve this question 
we entered upon an examination by auscultation of the other 
side of the chest; there was, here, no evidence of the exist- 
ence of tubercles, in any great numbers, but, from the fact of there 
being some dulness of percussion, there was reason to suspect their 
presence,though not to determine it with any certainty. Besides, from 
the circumstance of the mutability of the situation of the pain, as 
there had been, you know, a previous attack on the other side of 
the chest, the existence of tubercles was rendered probable. It is 
a law of pathology, that, if a pleurisy appear on one side of the 
chest, and some time afterwards show itself on the other, it, in all 
likelihood, is dependent on the presence of tubercles. This law of 
the double pleurisy, as it is called, was discovered by Dr. Louis, 
and, in most cases, may be relied on with certainty. I infer, then, 
that, in this case, the pleurisy was probably tubercular. 

Besides the suspicion of tubercles as a predisposing cause of 
pleurisy, the patient is labouring under an undoubted disease of the 
heart. It began during the acute inflammation of the early part of 
the winter, W'hen the pericardium was involved at the same time 
with the pleura. As a consequence of that inflammation, we have 
hypertrophy and dilatation of the heart. 

The treatment of this patient has been active ; she was bled to 
sixteen ounces, was cupped, and has since taken tartarized anti- 
mony and digitalis. Under these remedies, with rest and restricted 
diet, she is rapidly improving. 

The remedy here used, tartar emetic, is found to answer perfectly 
well in the management of pleurisy. It increases the sweating, 
and promotes absorption directly; the digitalis has a similar action 
through the medium of the kidneys. In pleurisy, when the inflam- 
mation is circumscribed, local depletion is the best treatment. This 
acts very promptly in serous inflammations, although it has but 
slight influence over the inflammations of parenchymatous struc- 
tures. In the latter case relief is afforded only in proportion 
to the quantity of blood abstracted, while in pleurisy it is in pro- 
portion to the nearness of the point of abstraction to the seat of 
pain. The pain is relieved, also, by the application of warmth 



454 GERHARD'S CLINICAL LECTURES. 

to the part, by poultices and fomeDtations. These, however, are 
not to be withdrawn suddenly, or without the substitution of a thick 
pad of carded cotton or wadding; otherwise they only do harm, 
by the alternation of heal and cold which takes place. The advan- 
tages of these local applications cannot be too highly estimated. I 
often rely more upon them than upon more powerful remedies, 
which, if they relieve pain, at the same time diminish the strength. 

The treatment of ordinary simple pleuris}^ is Dot a very compli- 
cated affair. And I wonld remark, that every case, in which there 
is DO positive evidence of a change in the fuDctions of nutrition, 
even though there may be strong ground of suspicion of a tuber- 
culous or other chronic disease, is to be regarded in the treatment 
as a simple pleurisy. The treatment of Dr. Louis, which I do Dot. 
however, follow in all cases, consists in small bleedings, combined 
with the internal administration of tartar emetic, nitre, digitalis, 
and diuretics. Of sixty cases that J saw him treat, be lost not oDe, 
It may be inferred, that is an effectual plan of treatment for 
simple pleurisy. I may add, that, in a simple case, if effu- 
sion take place, you need not be very uneasy, if it is slow to 
absorb, provided the case is othenvise proceeding well- 

Of the remedies, by which chronic pleurisy is to be managed, 
(meaning, by chronic pleurisy, cases of more than a month's dura- 
tion,) I shall not now treat in full, gi^dng you merely a general 
snmmary of them. Blisters, which, in the early periods of acute 
pleurisy, are not often necessary, and do harm twice for once that 
they do good, are of signal service in chronic pleurisy, scarcely ever 
doing mischief, and often affecting a rapid absorption of the liquid 
effused. They are to be applied not once, but repeatedly. Under 
their influence, absorption sometimes takes place, with astonishing 
quickness : indeed, it seems, in a few instances, as if the fluid was 
directly poured out from the interior of the chest to the blistered 
surface by a sort of endosmosis. Mercurials, in small doses, are 
not much used by the French, either alone, or in combination with 
squills and digitalis. But in cases approaching in character to 
hydrothorax, great advantage will be derived from a treatment 
with calomel, squills, and digitalis, or the simple action of the mer- 
curials alone, either piashed to ptyaiism, or nearly so, i«dll be found 
verj^ powerful, both in the advanced stages of the acute and in 
nearly every period of chronic pleurisy. Even an obvious but 
slight tuberculous complication does not always forbid the use of 
naercury in these cases. In addition to treatment by medicines ; 
travelling, a sea voyage, distractions, a simple change of place, 
will be of much service. The importance of travelling is greatest 
in those cases in which we fear the complication of a tuberculous 
diathesis- Whether there be already formed tubercles in the long, 
or merely the constitutional tendency to these affections, I am 
quite sure that by this means and by attention to other hygienic 
circumstances, patients are often preserved from a threatened 
consumption. 



TUBERCULOUS PERITONITIS. 455 

In addition to the case illustrative of one of the most simple serous 
inflammations, I shall say a few words respecting another case, 
in which pleurisy occurred, as a well marked complication. The 
case was one of pneumonia, consecutive upon tubercles, the existence 
of which was known by unequivocal signs at the upper part of the 
lung. There was something, however, engrafted on the pneumonia. 
This was pleurisy, which was detected by a sign which often occurs 
in the later stage of the affection, and is then pathognomonic, the 
bruit de frottement, a sound caused by the friction of the surfaces of 
the pleura, lined with false membrane, upon each oiher. It resem- 
bles the sound produced by the rubbing of leather or India rubber, 
and is the same grating sound that was heard over the heart of the 
man Robb, but in the present case it is produced by respiration, and 
is synchronous with it. It is, also, fugitive in its character, and dis- 
appears when the membranes become consolidated, 

I shall conclude with one other case, which terminated fatally a 
few days since, demonstrative of one of the causes of serous inflam- 
mations, the details and phenomena of which will serve as a key for 
future investigations. It was a case of chronic tubercular perito- 
nitis. My reasons for this diagnosis were based upon the conforma- 
tion of the abdomen, which was irregularly distended with gas, upon 
the existence of lancinating, griping pains, or alternations of cos- 
tiveness and looseness of the bowels, and upon the pain caused by 
motion, or the distension consequent upon eating ; there was, besides, 
nausea and vomiting. The peritonitis occurred here without any 
obvious cause, and was, therefore, not primary. For there is a law 
of the economy that chronic peritonitis is nearly always, particular- 
ly in young persons, dependent on the presence of tubercles. In addi- 
tion to this general law of pathology, the great alteration in the nu- 
tritive functions made the diagnosis of the development of tubercles 
much more certain. It was, at first, doubtful, from the large disten- 
sion of the abdomen from serum ; but the water here was soon ab- 
sorbed, and there was no recurrence of ascites. There was evidence 
also of tubercles in the lungs, although not very decidedly marked. 
Had there been no physical signs of phthisis the case would have 
been still positive, but we found a sufficient number of signs for the 
local diagnosis of tubercles. 

Most commonl}^, tubercles appear in the lungs of adults before 
they are deposited in other parts of the body ; but, in this instance, 
the application of this general law failed. The patient, some days 
before his death, was seized with sudden prostration, under which he 
rapidly sank, and with some increase of the abdominal pain. 

After death, the following appearances were discovered. There 
was effusion of serum and pus into the abdomen ; in the upper portion 
there was merely serum and lymph, and, in the lower, the intestines 
were agglutinated by false membranes perfectly organized, not vas- 
cular, but there was red injection in the upper part from a more 
recent inflammation. The cause of this diflference was perforation 
of the intestines from tuberculous ulceration of the glands of Peyer, 



456 GERHARD'S CLINICAL LECTURES. 

two of which had ulcerated through all the coats of the intestine 
into the peritoneum. The pathology of these perforations is the 
following : — A tubercular follicle in the intestine enlarges and soft- 
ens, and is discharged into the calibre of the gut. The ulcer left 
does not heal, and, passing into the chronic state, advances towards 
the serous covering of the intestine, which is sometimes destroyed. 
The peritoneal inflammation is only an attempt of nature to preserve 
life by preventing the discharge of faecal matter into the peritoneum. 
It fails, because the mischief done is too considerable to admit of 
reparation. 

In the lungs, the only evidence of the presence of tubercles were 
half-a-dozen gray granulations, that could be felt, but scarcely seen ; 
while, in the peritoneum as well as in the intestines, they existed to 
such an extent as to cause disorganization. This disease is unusually 
rife among negroes ; indeed, it is sometimes called consumption of 
the negroes, in the southern parts of our country. It rarely attacks 
adult males, more commonly females, and is very prevalent with 
children, in whom it forms one of the diseases known as tabes 
mesenterica, although the mesenteric glands are not invariably 
affected. 

To recapitulate my remarks of to-day: — Serous inflammations 
may appear as primary and secondary. When primary, they are 
not dangerous, except in the brain ; but they are so when secondary, 
because complicated with some previous lesion, and occurring in 
exhausted subjects. They are to be treated, in both instances, on 
pretty much the same principles, by depletion, and acting on the skin 
with alteratives in the more chronic stages. If excessive pain 
exist narcotics may be used to relieve it, with the topical applica- 
tions you may see every day employed at the hospital. 

For the proper study of tuberculous diseases, gentlemen, a know- 
ledge of the pathology of serous membranes is indispensable. Pre- 
vious, then, to entering upon the examination of the former aflfections, 
I have introduced the subject of serous inflammations to facilitate 
our future investigations. The study of tuberculous diseases is not, 
as you have also seen, to be confined to the chest, but to be extended 
to all the organs of the body, as you wall more fully learn at a 
later period. 

The tuberculous afl^ection of the abdomen, which has been under 
consideration to-day, though not the most common form of the 
disease in our latitudes, is one of the most prevalent in southern 
climates, and is on that account the more interesting to many 
ofyou. 



i 



ACUTE INFLAMMATIONS OF THE HEART. 457 

LECTURE IV. 

Acute inflammations of the membranes of the heart. — Pericarditis. — Endocarditis.* 

During the past summer I have very frequently alluded to the 
inflammations of the membranes of the heart. It has so happened 
that we have had a very unusual number of these diseases; you 
have seen more cases of the kind within the past six months than I 
have observed within the last two or three years, and it is very 
improbable that you will again witness so many cases of these 
aflfections, in the same short space of time. The serous inflamma- 
tions have been almost endemic in our city, and. if we except a 
moderate proportion of bowel affections, they have constituted the 
prevailing diseases of this period. 

It was for this reason that I commenced the course with- acute 
rheumatism, and then passed on to the consideration of the serous 
inflammations so closely connected with it. Amongst these, the sub- 
ject of the membranous inflammations of the heart was accidentally 
introduced; but I did not then point out to you the numerous inter- 
esting questions arising from the study of these inflammations, which 
you will find of diflicult diagnosis, unless you are thoroughly ac- 
quainted with their pathology and with the means of physical explo- 
ration. Without the aid of the physical signs of the disease, the 
inflammations of the heart cannot be recognised, except in a very 
small proportion of cases. You have had a recent illustration of this 
fact: a patient, whose case I shall presently detail you, has been 
evidently labouring under pericarditis of considerable intensity ; the 
eff"usion of lymph and serum occurred, as it were, under our own 
eyes, and you were able to trace the gradual consolidation of the 
lymph, when adhesions began to form between the two surfaces of 
the pericardium, yet the patient complained of no pain what- 
ever in the chest, and no uneasiness other than t'hat caused by the 
rheumatic inflammation of the joints which preceded the pericar- 
ditis. In but two or three cases was the pain sufficiently consider- 
able to induce us to suspect the occurrence of any aflfection of the 
heart ; one of these cases, attended with pain and the best 
marked, was that of Robb, which I mentioned when speaking of 
inflammatory rheumatism. He sufl^ered some pain, but it was 
usually inconsiderable, until his entire recovery. The other two 
were blacks, who were affected with inflammation of both mem- 
branes of the heart, and recovered, but died afterwards of a con- 
secutive dropsy. These latter patients had recovered entirely of 
the cardiac affection, and, in all probability, would not have fallen 

* This lecture was given some months after the preceding. 
39 




438 GE^WAMB-g GLiDV'ICAL L£CTI"EES. 

i^cSiimiffi to tlie dinigK|^ lad llief imft baak h.ixmiT&d oocler a csmDero. s 

move luDf line hssHraiy cf ifae cases, jou will 

sj^ns eqpnallj lAmBme^ I can affirm thst the 
ntsit owni^ to a want d ajppuDcialiion <»f tliesr 5 ^ 5 
in yoQBT pn^Eooe wilth liie most scr u j ' u i l' us 
acoairacj, and joa can bear wittness to ttbe pitecaoitioes taken lo 
efiiGit eveiT ptadicabfe agpaptogn in the casge. Tlhe ioSamiDalioDs : :^ 
libe faeait are^ ffaQnd&Bie;,to a grealt degroe, latienit, and jod ii::r. 
csooinience shcir stodj, widb ttfae convidion that ttlbeir diagnosis f 
inqMnsibie^ in a lai^ pnpoitlian <^ cai^s^ wilbont a ihoro::^ . 
^now^bd^ cC their patiBoltagy and a sndSicient acqoaiDtarjce v^ . -. 
Iftie phjiacal sa^as of diflRa^BR. Bast if tiois luBow9cdge be possesses. 
and Sonne dT yon iiai^ aliready attained ia, thone is mo part of 
miedicine move pesibcdj demoastrative in its dnLmct^-, &r wioiich 
is ^vemDBd b|^ more onwaryiEg Hams, as to the pragf^^s and teroQi- 
of these diseases. 
I will now idate to joa sanoeflf tibese c^ses. zui we can coinpare 
^ to ascertain how for these re ' 1 re confirQiec : 

invaiidaited bjp jour own «)bservalion. A : : • ? '■- :ii hare bef :. 

eye-witnesBEs of tie feds which I dt ne circuni- 

of the cases willl, therefine;, fee more oon^^i^'^iy impressed 
lindsand win cauiy wiah tfaeon a force of coiiFJclioD and 
of dettailB wfaidb cpoM never result from a poirelj 
lednreL. 
"He first case I shall give joo is that of a patient, now conva- 
r waids from pericaiditB, ie:s "^' "^' rr.-; :.Tr>licated "with 
of the intsnznl membrane of : A occ aired, 

mraonly the case, daring an ^\iix^£. ox a : ^le indamrns- 
toiy ihmmatiwn, and had just ajpjpeaied when the patient cb r : 

1^ iMowiDg sjmptoOK were dictates 




"■ David Daigan, aged t]iub%-ei^hl, & iimeJniner, accustomed to 
diiid^ fiedjy; enteired my waid EEpbaBher ths M. On the 2S± of 

AjDgioa, ailer diinlkiii^ rather moi« finoEly than osnal, he was taken 
wish oonvnlaions and became a^gfady derai^ieJ ; hs was bled, re> 
inroed ficHT m dhost time to consdioiKnQss, and again becaime incapable 
€Bf leoofilecilion. On the 19th he was stopid and conld answer no 
qBssbkns;~the sb]|Hir was- macoompamed by <distortion or active 
dteiiriiiKin. ISo mntteiii^; laa leftnni of convulsions. Digestive 
lincitBOiDsgood. Qe wascii|!pedfieellytotlie DL'^ha t^ice : pedHnvia 
weie appSied; ha toolk natie and the efierTt : : 
pmged. ImtwodaysherecovonBdhKsimie 7; iiv.:^.^* :..i 

ConsciousDess not quite perfe:. ~ -:d. On Ms 

to eosKcioosness, h^ had pifiins in ooin legs, hands, aod 
with swdHi^. Fa^Bsm the 1st to the 2i lljere was in- 
crease cf pam and heal, and on the ^ thore was redness. ^ : 
or pal|MtatiMNas. HlBeie was inteose cephalalgia, which ta is 
by ODifeng^ For the last three or fosar yeai^ he had :3ui- 



PERICARDITIS AND ENDOCARDITIS. 459 

tering of the heart after exercise, and was short-breathed at the 
same time. This began after an illness of seven months duration, 
the result of intermittent fever. He had rheumatism ten years ago, 
after being exposed to rain, and tw^o or three limes before, but 
merely local in the shoulders, not confining him to bed. He recol- 
lected no other illness, never had syphilis. At the beginning of the 
pains, on the 28th, had a severe chill, but none after. 

"His condition, on the 2d, was as follows; swelling, heat, and 
pain in the ankles and feet ; slight swelling of the knees ; and redness 
and swelling of the hands in nearly all the joints. Some pain, but 
no swelling, in both shoulders, but none in the elbows. Pulse 
ninety, full, nearly regular. Tongue moist and natural. iVppetite 
good; no nausea; stools regular. Skin generally warm, scarcely 
moist. Both sounds of the heart heard in the whole prsecordial 
region, varying, but never perfectly natural. The first sound more 
or less roughened, the second heard distinctly, rather sharp : be- 
tween the two, or rather at the commencement of the second, was 
heard a very evident bruit de frottement, which could be detected 
over the whole preecordial region, but was most distinct over the 
left margin of the sternum, more marked in the erect than in the 
recumbent posture. Impulse of the heart increased and irregular. 
Percussion dull from the right margin of the sternum to the nipple, 
and from the fourth rib downwards. No pain, no dyspnoea, almost 
no cough, no uneasiness on percussion. Spinal tenderness from the 
seventh dorsal vertebra to the fifth cervical, more severe on the 
spine than on the adjoining parts. Cups were ordered to the whole 
length of the spine, with a sixth of a grain of tartar emetic and 
opium each, every two hours, and low diet. 

"On the 3d, there was great alleviation of the rheumatic symp- 
toms. No cough or pain across the chest ; no palpitation. Creak- 
ing sound in the prsecordial region more distinct than on the 2d, 
extending over the whole region, and synchronous with the diastole, 
varying in intensity and tone. Impulse of the heart diminished, 
more diffused. Sounds much less loud, and both heard distinctly, 
the first less rough than on the 2d. Prominence rather greater. 
Percussion dull to an inch and a half beyond the nipple, thence to 
right margin of the sternum. Respiration posteriorly, vesicular 
throughout the chest, resonance of the voice doubtful; opium and 
tartar emetic continued, twice the quantity of the former, with cups 
to the prsDcordia. 

" On the 4th the pain and swelling were rather less, but there 
was great weakness, which may have been owing to the tartar 
emetic. Other symptoms better. Eight ounces of blood had been 
taken from the chest, by the cups. Percussion now quite clear 
within the nipple, dulness extending merely an inch and a quarter 
from mid-sternum. Sounds of the heart much louder, the first 
offering only a moderate bruit de soufflet; the second, near the 
point of the sternum almost replaced by a simple creaking sound, 
which prolonged itself also into the first, but less distinctly ; heard 



460 GERHARD'S CLINICAL LECTURES. 

all over the heart, less towards its left margin, very loud along its 
whole sternal region, at times giving a musical tone. When the 
patient was erect, the impulse of the heart was stronger, creaking 
more frequent, converted into an incessant grating. Eight ounces 
of blood were again taken from the prscordia by cups, and the 
opium and tartar emetic continued. 

" On the 5th, the pain was less severe in the hands, more so in 
the shoulders and muscular parts of the arms; soreness in the 
muscles of the thighs, less in the feet ; increase of swelling and 
puffiness in the knees, but not of pain and swelling. Xo spinal ten- 
derness, cough, or oppression : sleep disturbed by pain ; promi- 
nence greater than yesterday ; percussion clear, however, except 
for an inch and a half at the point of the sternum ; impulse of the 
heart greater, clearer, sharper; first sound diminished, grating 
much less distinct, heard chiefly at the point of the sternum. On 
sitting up, the action of the heart was stronger, the grating much 
more distinct, heard under the same circumstances as before ; three 
stools since last evening ; when he took half a grain of ipeca- 
cuanha and five grains of Dover's powder, twice. To-day, five 
grains of Dover's powders, four times a day, and cups to the 
spine. 

'• On the 6th, no swelling in the knees, almost no soreness, less 
of both in the feet, none in the left hand, almost none in the right; 
soreness and swelling in the shoulders not diminished; no soreness 
of the back or breast. Pulse ninety-two, regular, and softer. 
Sweating profuse, no chilliness. First sound of the heart very 
short and faint. Second, loud, masked by the creaking sound. 
Percussion duller, to an inch within the nipple; impulse rather 
stronger. Cups between the shoulders, and Dover's powder con- 
tinued. 

" On the 7th, countenance gav ; shoulders better; no swelling 
of the hands, almost no stifi^ness : knees natural; very slight swell- 
ing in the ankles, with a little pain in the right, l^o spinal tender- 
ness. (Has been cupped four limes ; twice to praecordia, eight 
ounces, each time; twice to spine, six ounces ; twice cupped, before 
his entrance, to the nucha, seven ounces ; and had been bled from 
the arm.) Pulse quick, regular, ninety-five. 'So prominence in 
the prascordia. Percussion perfectly clear. Dulness very incom- 
plete everywhere. Impulse of the heart more clear; first sound 
prolonged ; creaking in the second limited to the point of the 
sternum, disappearing when he rises. Sweating profuse, constant. 
Urine rather increased. Xo chills. Dover's powder continued; 
hop poultice to the feet. 

'-On the 8th, soreness almost ceased in the feet, a little effusion 
in the knees, but no increase of pain ; slight soreness in the points 
of both shoulders. Pulse one hundred and eight, thrilling, regular. 
Sweating continues. Impulse of the heart much stronger, first 
sound nearly natural, a little prolonged: bruit du cuir so faint at 
the beginning of the second that it would have seemed doubtful, 



PERICARDITIS AND ENDOCARDITIS. 461 

if not previously heard. Treatment continued with cups between 
the shoulders. . 

" On the 9th, has pain only in the knees and hips ; less in the 
shoulders since the cupping. Sweating still continues. Pulse one 
hundred and fwo, quick, thrilling, and resisting. Appetite good; 
no nausea ; three or four stools daily. Respiration now heard 
over the whole prsecordial region ; impulse stronger, creaking 
quite decided in the second sound ; first still blowing, less than last 
evening, when the pulse rose ten to fifteen beats. Dry cups were 
applied to knees last evening with relief to the pain. Treatment 
continued. 

*' On the 11th, no pain in the hands ; some cephalalgia. Pupils a 
little contracted. Some wrinkling of forehead. Expression anxious. 
Pulse one hundred, full, thrilling, softer than yesterday. Slight 
subsultus ; talking in sleep, says he is accustomed to it when well ; 
sweating continues ; five stools in the twenty-four hours; legs re- 
stored to motion, almost no swelling; stiffness of right shoulder and 
arm, including elbow; slight of left ; feels no uneasiness in the 
chest; a little soreness apparently in the pectoral muscle of both 
sides; first sound of the heart and impulse natural; creaking 
scarcely heard ; (has taken no medicine in the last twenty-four 
hours,) four ounces of wine in whey, and an assafoetida plaster to 
the epigastrium. 

" l:<ith. Last evening, about seven o'clock, had more tremor, 
more subsultus, countenance the same ; took four ounces of the 
assafoetida mixture, every two hours. Enema of twenty drops of 
laudanum. Slept well during the night, awoke once or twice only. 
Pulse ninety-six, full, soft ; pains not increased. Soreness felt now 
only in the shoulder joints. Bruit de soufflet harsher than yesterday ; 
a little rasping, creaking indistinct ; second sound very clear. Per- 
cussion nearly as before, a little less clear ; assafoetida mixture con- 
tinued ; wine omitted : full diet. 

"13th. Muttering during sleep ; pain less; two stools in twenty- 
four hours. Impulse of the heart louder and clearer ; both sounds 
louder, particularly second, which is still a little blowing, still sub- 
sultus ; sweating. Pulse ninety-two, feeble, regular ; continue assa- 
fcEtida. 

•' 17th. Still has pain in legs and arms ; drowsiness constant ; 
no subsultus; intellect quite clear. Pulse one hundred, regular, 
small ; motion returned to every joint, but some stiffness in shoulders 
and knees; sweating abundant. Both sounds of heart heard; 
creaking not ceased ; more diflfuse, less loud. Dulness of percus- 
sion not increased. Chamomile tea. 

" 18th. Sitting up; no pain except slight in shoulders and knees; 
sounds of heart natural, except slight creaking in second. Conva- 
lescence confirmed. 

"19th. Perfectly free from pain, except when moving; then 
suffers from soreness of limbs ; skin cool, pleasant; appetite good ; 
sounds of the heart clear; creaking barely perceptible. 

39* 



462 GERHARD'S CLDflCAL LECTURES. 

*' 20th. Continues well : remains a few days longer to confirm 
his convalescence." 

When you examine the history and progress of this case, you 
will see upon what lacts the diagnosis of pericarditis is based. We 
must then examine other cases which have terminated fatally, in 
order to test the correctness of the laws of diagnosis, which I shall 
lay down. We have, fortunately, lost no patient in the present course, 
during the continuance of the pericarditis; but we shall be able to 
obtain the necessary evidence from an examination of those cases 
which terminated fatally of some accidental disease after the ter- 
mination of the pericarditis, and we then can compare those cases 
with others that have terminated unfavourably at a previous 
period.* 

The signs of pericarditis in one patient varied according to the 
stage of the disease. During the period of effusion, which had 
already begun when the patient came under our observation, five 
or six days after the commencement of the rheumatism, we had 
the physical signs of pericarditis, which are clearly described by 
Dr. Louis. That is, flatness on percussion to a much greater ex- 
tent and to a more considerable degree than occurs in a healthy 
subject, decided prominence of the praecordial region, which was 
distended and raised up by the liquid, and dulness of the sounds of 
the heart and feebleness of impulse. Now, these signs become the 
more characteristic from their constant variation ; the quantity of 
liquid scarcely remained the same for two consecutive days, and 
you, therefore, found the signs of the disease to increase during the 
time that it advanced, while they diminished very rapidly when 
the pericarditis declined. Had the dulness and the prominence of 
the prsecordial region been permanent, the case could still have 
been recognised, but there might have remained some room for doubt; 
for chronic enlargement of the heart, particularly if complicated 
with effusions of serum into the pericardium, resembles a case of 
pericarditis in its physical signs. The resemblance ceases when 
you watch the case for several consecutive days. 

There was another sign indicative of pericarditis, which also 
served to point out to you the variety and stage of the disease. It 
was the sound produced by the rubbing together of the two surfaces 
of the pericardium covered with lymph. This sound occurs during 
the systole and diastole of the heart, especially the latter, it was, 
therefore, most evident during the second sound of the heart which 
occurs during its dilation. This new sound was so loud as, in some 
measure, to conceal the natural second sound of the heart, which 
was, however, never entirely destroyed, but could always be 
detected by a practised ear, as it were, combined with the new 
adventitious sound. The second cardiac sound was not lost, be- 
cause it depends on valvular contraction, and the' valves o{ the 
heart remained nearly in the normal state; now, had the disease 

* Some cases of this kind were then mentioned. 



PERICARDITIS AND ENDOCARDITIS. 463 

been complicated with much inflammation of the internal mem- 
brane, as was the case with the man Rubbj to which I have previ- 
ously alluded, the motion of the valves would no longer have 
remained free, and we should have found either that the second 
sound was altogether lost, or much changed from its natural cha- 
racter. The cause of the grating sound is nearly the same in 
inflammation of the pericardium and of the pleurae; that is, in both 
cases it arises from the friction of two surfaces of serous mem- 
branes more or less coated with lymph ; it is not precisely similar 
in the two cases, because the quick action of the heart difl^ers greatly 
from the slow gradual movement of the lungs in the act of respira- 
tion. The grating sound of pericarditis, therefore, is more sharp 
and quick, but less loud and prolonged than that of pleurisy. It is 
useless to describe this sound to you, for you have heard it for your- 
selves, which answers better than any description; those who have 
not heard it, may readily distinguish it by its creaking, like the 
sound produced by rubbing together two pieces of moist leather, 
whence it has been sometimes called the " bruit de cuir," or lea- 
ther sound ; a trivial name, which is by no means so expressive as 
that of rubbing or grating sound. It cannot be recognised by one 
not previously acquainted with the natural sounds of the heart, 
with which the slighter shades of this adventitious sound may be 
confounded. You could distinguish it readily in the present in- 
stance by a careful analysis of the sounds when you found that 
the sharp clear tone of the second sound was more or less obscured 
by this rasping sound extending over the whole anterior surface of 
the heart, especially at its middle portion. There is but little diffi- 
culty in distinguishing the grating sound of pericarditis from the 
rasping sound caused by thickening or vegetations upon the valves; 
the latter is more frequent in the systole, is always heard most 
distinctly at the region of the valves, and is not attended with a 
sensation of glowing, which is quite perceptible to the touch in 
most cases of pericarditis. When there is but little efl^usion the 
grating sound is more important as a sign, for there is this very 
dulness on percussion and no prominence. 

As the lymph became consolidated, the grating sound gradually 
declined, but it has not yet disappeared, although the patient is now 
in full convalescence. Nor do you generally find that this sound 
wnll disappear quickly; for, if the lymph form prominences on the 
surface of the heart, it may remain for several months, at least until 
it is so far absorbed as no longer to present rough projections for 
the grating of the two surfaces together. 

The sounds of the heart, properly so called, were both distin- 
guishable throughout the whole of this case; they were somewhat 
feeble, had lost a little of their natural clearness and seemed distant; 
but neither of them was either very much changed, or had lost its 
due proportion. In simple pericarditis, you will find that this is 
usually the case. It is true, that the motion of the heart is never 
quite free, and its sounds do not retain their full development, but 



464 GEKHARD'S CLINICAL LECTURES. 

it is also true that the slight aberration from the normal sound which 
occurs in simple pericarditis, is very different from the rasping or 
very rough bellows sound heard in cases of endocarditis ; whether 
this latter disease be simple or merely a complication of the pericar- 
ditis. You had a beautiful illustration of this distinction when you 
examined the case of the patient Robb, which was described when 
speaking of acute articular rheumatism. In him there was both 
endo and pericarditis, and we had the distension and dulness of 
sound indicative of pericarditis, with the rough and harsh sound, 
caused by the thickening and consequent stiffness of the valves. The 
chain of proof of what I have just advanced is, with me, conclusive ; 
for I have seen cases of both endocarditis and pericarditis quite 
uncomplicated one with the other, and, therefore, well suited for 
studying the signs of these diseases in their simple state. I 
have again seen other cases in which the symptoms of one dis- 
ease greatly predominated, without being perfectly unmixed one 
with the other. Some of these cases terminated fatally, and the 
examination after death proved the correctness of the diagnosis. 
The most recent cases of heart disease of the kind to which I am 
now alluding, were furnished by two patients affected with pneu- 
monia ; both died of the pneumonia, which was aggravated by the 
. disease of the heart, although this latter affection was not, in itself, 
sufficient to cause death ; and we could, therefore, test our diagnosis 
as applied to a membranous inflammation of the heart of moderate 
severity and in itself not fatal. 

The first case occurred in the last winter; it began with laryngitis, 
attended by extreme prostration ; the patient was then attacked 
with pneumonia, of which he died. During the course of the pneu- 
monia, the patient was taken with pericarditis ; there was a manifest 
dulness in the prsecordial region, a slight prominence, and a distinct, 
though feeble creaking sound, chiefly heard during the dilatation of 
the heart. The sounds of the heart scarcely differed from the nor- 
mal standard, although the impulse was somewhat feeble. As there 
was some obscurity in the case, the patient was, at my request, 
examined by my colleague, Dr. Pennock, who concurred with me 
in the diagnosis. The patient died, some days afterwards, from the 
pneumonia ; on the autopsy we found patches of false membrane 
scattered over the surface of the pericardium, proving the existence 
of pericarditis. There was no liquid in the pericardium ; this again 
corresponded with the accuracy of the diagnosis, for, previously to 
the death of the patient, the pericarditis had evidently declined, and 
the dulness on percussion had been gradually replaced by the natural 
resonance. This case, which occurred during the course of the 
present winter, afforded conclusive evidence of the actual relation 
between the signs of pericarditis and the corresponding anatomical 
lesions. 

The second case presented itself more recently ; it was that of a 
man ill with pneumonia which had advanced to the period of sup- 
puration, previously to his admission. This patient offered, during 



TUBERCULAR MENINGITIS. 465 

life, the signsof uncomplicated endocarditis; there was a dull confused 
action of the heart, neither of the natural sounds being very distinct ; 
their rhythm was also somewhat changed. The impulse was diffu- 
sed and labouring. There was but a very slight increase of the natu- 
ral dulness on percussion, at the prsecordial region, and there was no 
creaking sound. I considered this case as one of endocarditis, with- 
out much valvular alteration, and mentioned my reasons for this di- 
agnosis to several of you, who were then present. The patient died 
of the mingled effects of the pneumonia and the endocarditis, and, 
as you remember, we found the internal membrane of the heart red- 
dened, as well as that of the orifice of the aorta ; it was covered 
with a delicate membrane that could be detached from it in strips 
of considerable length. On examination of this membrane by the 
aid of a magnifying lens, we found that it was apparently organized 
and traversed by numerous blood-vessels. 



LECTURE V. 

Tubercular meningitis. — Case. — Anatomical characters. — Symptoms. 

I SHALL continue to-day, gentlemen, the subject of inflammations 
of the serous membranes, and take up the consideration of a case, 
which came under your notice at the hospital, a day or two since, 
and presented an example of inflammation of the serous membrane 
investing the brain. We may the more properly enter upon the 
subject at this time, as it will facilitate our future examination of the 
diseases of the substance of the brain. 

The patient, of whom I have spoken, died in the ward No. 3, and 
was not under my immediate care. He was a carpenter by trade, 
and had suffered severely in early life from scrofulous affections ; 
both his feet had been ulcerated from this cause, some time previous 
to his admission. He also laboured under disease of the heart, 
and entered the hospital for hydrothorax, the cavities of both pleurae 
being filled with water, and suffering under an extreme and dis- 
tressing dyspnoea. He w^as relieved from these symptoms by sali- 
vation, combined with the use of digitalis and squill. He got rid 
of his shortness of breath, and was able to work in the out-wards of 
the establishment, where he continued, until the breaking out of the 
epidemic of measles, with which disease he was taken on the second 
of April. He suffered considerably from the measles, but gradually 
became convalescent, till, on the twenty-eighth of April, he offered 
some symptoms of a cerebral affection ; that is, unusual dulness, 
stupor, and oppression. On the first of May, the cerebral symp- 
toms became so well marked, that they were recognised as those of 
meningitis by the physician in attendance. At that date he was 
in the following condition. For two days previously he had mani- 



466 tI .£ ._ ^ CLINICAL LECnrKB^ 

fested g T -5 5 r'? with occaskmal incohereiice aiid halhieiiia- 
tioos. ^ r full and strong, the bisferiens character, 

which a i :? : ence from meases, ha^^^ng ceased from 

the twe ■ 7 is bis feriens poise, a sign of conimie^ 

scence : - 3sweD marked in this case, ceased, 

yon see rfth the new disease of the braioL 

The tfc: ; i ~_ issameatam of the blood was 

toleral - M iiKjr sizj, about one-hdf of 

it bdng 5i 7 i r swered questions slowlj. 

The c : s _ T" r tongoe pale, nMnst, 

slightly r : 7 f : t 5 r _ '.boogh he still recog- 

nised objc-i;;^ iXk> eejiiiakLlgia. T r : t 5 : r.ant ; not painfnl 

on pressure, except in the hjpogj. 5 r^ons, where it 

was als . : r 7 : .lad 3at on pe : : 5 5 ; . ? e ; .:ssioQ of the left 
adeof 7 t: 5 nant. except :: t : egian; respira- 

tion pc:i 7:5; : the righ ess so than 

the kh - T V ":=--: 5 ^ - 5 : T-^longed, 

attende : r j : 5 \: - r ^ ; : of the 

nipple, ; e 5 ; _ 7 : : :' : :. 7 i 5 : s : .; : :: : : f f : ■ 7 : : i ; ■ f 7 r the 

seccHid -. - :.z 5f: -: s ;.:::: :;,r-T.7:. :~i'.i 



over ar. . .:. 5 : - / : ? f ■ 7 : ■ 7 , ; ' ^ : 7 .-_ : .: j : ; . i : : 
salts an. .;-„:. n:^i ^:ii^:„i_, _.:_ ^ .:„£-;: :: :.i ;;-:e ::" L.i 
neck, dressed with mercorial cnntment. 

On the third the countenance was rather ies? :r • h e 

first, and he answered qoestions better ; had bee - 
before^ There was some grinding of the ter 7 e 
UMMleratdj warm and hot- Poise ninety per 
smaller. Conjonctiva moch tedder; a discharge 
erf* yellowish matter from the right eye. In . r :.; i . :. e, ere 
was some strabismos and increased stopor. An injection of oil of 
torpenttine and castor oil was administered, and c:old applied to 
the head. 

On the foorth there was rery great stnpor ; the eyes were closed, 
and the patient ccniM not be r^osed to answer qoestions. The head 
was torned to the :g : : ^^igbt eye infiamed as before; the 

popil of the 1^ e e 5 1 e sterday. Poise aboot eighty-five, 

irr^olar and ie : r 7 "els opened three times by the 

injection. Abd: 7 :'?':eaded. Cold to the head 

ccmtinDed; caic . : .J salts. The same day 

the man died. 

The symptoms here, yoo perce ■ : those which denote 

active, violent infiammation, bot were sunply eLolness of the intellect, 
stnpor, with grinding of the teeth, &gl 

The treatment was commenced by a bleeding which woold 
have been larger if the previous disease of the patient had not 
rendered him too feeble to bear it, and was followed by porging, 
and an attempt to mercurialize the patient, which latter failed, 
from the short time that elapsed between the administration 
c»f the remedies ai^ the man's death. 



TUBERCULAR MENINGITIS. 4G7 

The following appearances were found in the brain twenty-four 
hours after death. 

Marked adhesion between the dura mater and the membrane 
beneath. The vessels of the dura mater were more congested than 
usual. In taking the brain from the cranium about two ounces of 
fluid escaped. The large vessels of the pia mater were much con- 
gested ; the capillary vessels of a bright red tint, — inosculating. In 
the middle part of the right side, the convolutions were flattened; 
on this side, the injection of the pia mater extended to that portion 
dipping into the convolutions, and it adhered strongly to the cerebral 
substance. The injection and adhesions were less marked towards 
the posterior portion. At the anterior extremity, the arachnoid mem- 
brane was opaque; the injection and adhesion somewhat less than 
at the middle. On the left side this bright injection occupied the 
middle half and was confined almost exclusively to the small arterial 
vessels. Pia mater less adherent than on the right side. Arachnoid 
slightly opaque, throughout the whole extent presenting a few minute 
granulations, near the parietal protuberance. The cortical substance 
on both sides was of a rosy tint, a little brighter on the left than on 
the right. That portion of the arachnoid covering the fissure 
between the hemispheres, and at the summit of the brain, was 
slightly roughened. Corpus callosum softened. Fornix and septum 
lucidum pulpy. The right ventricle was larger than the left; the 
quantity of serum contained not known. The thalami and corpora 
striata were pale. At the base of the brain, the colour was in a 
great measure lost, from the commencement of decomposition ; but 
in the whole anterior hemisphere injection of the small vessels was 
manifest. There were small adhesions between the anterior lobes 
of the brain. Fissure of Sylvius, on the left side, strongly adherent, 
by a solid deposit around the vessels, part of which, in the form of 
granulations, was still distinct. On the right side the same thick- 
ening occurred around the vessels, but the newly formed matter 
was less abundant than on the left side ; it still presented tuberculous 
granulations, less in size than a pin's head. The arachnoid was 
opaque and extremely thickened ; the thickening of this membrane 
extended backwards over the chiasm of the optic nerves, which it 
slightly invested. Towards the cerebellum the thickening of the 
membranes became more marked at the upper portion, at the point 
of junction with the cerebrum; the double secretion was there 
distinct, consisting, in part, of minute granulations, beneath the mem- 
brane, and in its thickness ; and, in part, of a thick, opaque, hard 
substance, filling up the space between them. The cerebellum was 
firm, like the rest of the brain. 

There were no tubercles in the lungs, or the viscera of the abdo- 
men. The state of the lymphatic glands was unfortunately not 
noted by the gentlemen who made the examination. From the 
former scrofulous disease, these glands were probably tubercular. 

It is to be inferred, then, that the disease of the brain was hereof 
an inflammatory character, from the injection and thickening of the 



468 GERHARD'S CLINICAL LECTURES. 

arachnoid membrane. It was evidently of the tuberculous variety, 
from the granulations which were found scattered beneath the 
ara<;hnoid — it was a case of tubercular meningitis. The bright 
injection of the arachnoid, which is limited to the smaller vessels, 
is a very good diagnostic sign of inflammation ; had it been observed 
in the larger vessels merely, I should have regarded it as a simple 
congestion. In the present instance we have, then, only the alter- 
ation in the membranes of the brain, to account for the cerebral 
symptoms, as the substance of the organ is not at all affected. 

This subject of tubercular meningitis, gentlemen, is one that will 
present itself frequently to your notice, as it is a disease very 
common with children, and by no means rare in adults. It is 
generally slow and insidious in its progress, and requires a very 
careful examination to distinguish it, particularly in its early stage. 
I have taken for the subject of some general remarks to-day on this 
disease, a case in which we have had the pathological phenomena 
very clearly presented to us, and in which the indications, previous 
to death, were sufficient for a correct diagnosis of the affection. 
This case, I may remark, exemplifies the occasional effect of 
measles, in giving rise to the development of tubercles, to which I 
alluded at my last lecture. 

This individual, we learned, had had an attack of brain fever, (so 
termed by his mother,) many years ago, by which his mind was at 
the time considerably affected. This was probably a scrofulous 
inflammation of the same character as that which finally carried 
him off. Children may recover from these tubercular cerebral 
affections, and, at some subsequent periods of their lives, present the 
same symptoms in a more marked manner, from a new secretion 
or, as it were, second crop of tubercles in the membranes of the 
brain. So, patients may partially and temporarily recover from 
pulmonary phthisis, as was shown to you in a late autopsy, where 
co-existing with the cavities which immediately preceded the death 
of the patient, were distinct traces of the operation of a former 
cure, in the hardened cicatrices, which we found in various parts of 
the lung. The man whose case we are considering, had probably 
recovered from an attack of tubercular meningitis, early in life, and 
he might have remained well, had not the occurrence of measles 
awakened the slumbering tubercular disposition, and caused a fresh 
development of the aflfection, which now proved fatal. 

This subject of tubercular meningitis I investigated very fully 
some years ago at the Children's Hospital at Paris, and obtained 
some important results as to the nature and cause of the affection. 
The first point of inquiry, upon entering on the subject, is, have we 
any evidence of the existence of tubercles, elsewhere than in the 
brain and it^ membranes, in this aflfection ? In the children who 
died from this form of inflammation of the brain, I found tubercles 
in the bronchial glands or other organs of the body, as w^ell as in the 
substance and membranes of the brain, where they were found from 
the size of a pin's head to that of a large pea. 



TUBERCULOUS MENINGITIS. 4G9 

There \Vas but one evident exception to this rule, out of thirty 
cases, that were analysed in a paper, which I pubHshed in the 
American Journal, in 1834. In the exceptional case, there were 
tuberculous granulations in the membranes of the brain, but not in 
other viscera. The coincidence of tubercles in various parts besides 
the brain conclusively proves, that a general tuberculous diathesis 
existed in these subjects, for in no other class of acute disease does 
the same rule obtain. In a few cases, however, the tuberculous 
deposit may not appear except in the membranes of the brain.' 

Having determined the point as to the general tubercular nature of 
the disease ; the next matter to be investigated, is, the causes on 
which depends the development of the affection. Unquestionably, 
the scrofulous diathesis is the strongest predisposing cause of this 
affection, using the word scrofulous as significative alike of the 
tubercular and strumous temperament. In almost' all the cases in 
which the cerebral affection occurs in adults, a scrofulous disease 
has previously existed, and perhaps been cured in some other part 
of the body, as the lower extremities; the glands of the neck, the 
lungs, and elsewhere. As to the exciting causes of the disease, they 
escaped us almost entirely; in the majority of cases, at the Enfans 
iMalades, we could detect no antecedent fact, which could at all 
account for the development of the tubercular disease of the brain. 

The measles, however, in the case under notice, is to be looked 
upon as the accidental cause of the development of the disease; and 
I may make the general remark, that, whenever, in a scrofulous 
child, you have an acute disease accompanied with fever, you 
may look for the development of inflammation of the brain, and 
are to watch your case with exceeding care. 

The prognosis, in tubercular meningitis, must, generally, be more 
or less unfortunate, particularly in hospital practice. This deduc- 
tion I base upon the observations made by myself and my friend 
Dr. Rufz, at the Children's Hospital at Paris, where, for one or two 
that got well, forty died. Indeed, Charpentier, who observed ten 
years ago in the same hospital, went so far as to say that he never 
saw one case recover. Yet, in private practice you will find the 
results much more favourable. In the hospital at Paris, the children 
were badly fed, confined in close rooms, and the treatment pre- 
scribed was not so minutely carried into execution as in private 
practice. I have not seen many children with this complaint since 
my return to Philadelphia, but those cases which I have seen were 
generally but not always fatal. A striking instance occurred in the 
child of one of our nurses; she was a girl of four or five years of 
age, and recovered entirely, but a second attack came on, a year 
or more after the first, and proved fatal. 

The adults who are taken with tuberculous meningitis, nearly all 
labour under phthisis pulmonalis, which complication contributes 
not a little to the fatal termination of the aflection. These cases 
are, of course, not fair standards for estimating the powers of 
treatment. In many cases, also, of this disease, the existence of 

40 



470 GERHARD'S CLIKICAL LECTURES. 

tubercles in the iungs may oot be ascertained during life, although 
they may be found after death. This was the case with a negro, 
whom I examined some years ago at the Pennsylvania Hospital. 
(See American Journal, 1836.) Durhig life he had neither cough 
nor expectoration, but I found, after death, numerous miliary 
tubercles in the lungs, as well as in the brain ; in other words, the 
roan laboured under general acute tubercular disease, which, from 
similarity in the size and appearance of the granulations, must have 
commenced nearly at the same time in the lungs and brain, but 
had not attained a large size in either organ. Generaliv. w^e meet 
with the disease in adults, under circumstances that preclude the 
hope of a cure: but. in children you may entertain a fair hope of 
success, if you see tiie case early: if it has advanced so far as the 
second stage of the disease, you have but a slight prospect of saving 
the child from speedy death. 

The symptoms differ in children and in adults. In adults, the 
disease appears in patients actually labourinrr under phthisis, or of 
a decidedly strumous diathesis: while it ofien shows itself in chil- 
dren, who are in the enjoyment of tolerably good health, notwith- 
standing some latent tendency to scrofulous diseases. Whenever, 
therefore, in cliildren, the symptoms which I shall describe as cha- 
racteristic of the forming stage of the disease, present themselves, 
the physician should put himself upon the watch, though they are 
not to be looked upon as invariably indicative of the resuh in ques- 
tion. Tubercular meninjritis may besin in two ways : — First, it 
may come on abruptly, as ordinary acute meningitis, with vomiting, 
chill, and fever. The cerebral symptoms may appear, however, 
without even the prelude of vomiting : in adults this symptom is 
commonly wanting. When its approach is more gradual, the fol- 
lowing order of phenomena is observed : — 

For the first few days the child merely evinces unusual restless- 
ness and irritability, showing signs of excitement of the brain. He 
avoids light and sound, from the extreme sensibility of the eyes 
and ears. We have also s change in the imeliigence, if tlie child 
be old enough to permit such attention to be noticed. First, it is 
simply excited : the child is more lively and acute, and more at- 
tentive to external objects than before. Afterwards the counte- 
nance becomes changed : the cheeks are fiuslied. the eyes unusually 
briirht. and a well-marked frown and wrinkle are to be noticed 
on the forehead. This is one of the most important signs of the 
early stage of the disease; and at this period.it is essential to 
recognise all the s^nnpioms. and this peculiar expression you may 
consider characteristic. This, together with tiie bright red flush 
upon the cheek, the nurses in the Children's Hospital used to look 
upon as an unfailing mark of the approach of the disease. The 
decubitus is at this time but slightly altered. But we often meet 
with some secondary symptoms, which, although they are not 
always present, are of some moment : these are nausea or vomit- 
ing, constipation, and fever, which is at first of a mild character. 



TUBERCULOUS MENINGITIS. 471 

We now pass to the second stage, comprising the symptoms 
"which were first observed in the man who has just died ; those of 
the forming stage were lost in the decline of the measles. These 
s\'mptoms are delirium, which cannot of course be very accurately 
observed in children, particularly if they are very young. But 
some signs of it may be generally detected, especially at night, in 
the quick answers and altered manner of the child. This delirium 
differs from that of ordinary acute meningitis, in which the patient 
is violent, noisy, and loquacious. Here there is mere dulness and 
stupor, somewhat similar to the delirium of typhus fever; the child 
is not very violent, makes no efforts to walk about or to do mis- 
chief, but remains in a state of dull muttering. 

I was impressed by this peculiarity of the delirium of tubercular 
meningitis, in two cases which came under my observation at the 
Pennsylvania Hospital three years since. In one, of so moderate 
a character was the delirium., that the patient was admitted for 
simple insanity. The only other symptoms that attracted atten- 
tion, upon his admission, were a peculiar hobble and limp in his 
gait. We found the traces of several scrofulous disorders, which 
had been cured, and the man had also a slight cough, of which he 
had complained for two years past. The patient was constipated 
before his entrance, and shortly afterwards vomiting ensued, and 
then the cerebral symptoms became more decided. The paralysis 
occurred very early, from the coincidence of softening and inflam- 
mation of the substance of the brain with that of the membranes. 

At first, in fact, I thought it was paralysis, from mere softening 
of the brain. Afterwards, I began to doubt, and regarded the 
case as one of tuberculous meningitis : finally, the autopsy cleared 
up all obscurity. The paralysis was found to be dependent on 
softening of the brain, and the delirium arose from tubercular me- 
ningitis with effusion of lymph at the base. This complication of 
lesions necessarily gave rise to the intermixture of the symptoms 
of meningeal with those of cerebral inflammation ; in practice 
this coincidence is by no means rare, and it is not often difficult to 
detect it. The seat of the disease was here the same as in the case 
of the man Crane; the deposit of tubercles was along the blood- 
vessels, following the ordinary law which regulates the secretion 
of tubercular matter. 

Besides the delirium of the second stage, we meet with altera- 
tion of the senses, as in the case of Crane. The pupils are gene- 
rally dilated, moderately and gradually ; in some cases, they are 
contracted, but, as was observed by Dr. Stewardson in the present 
case, it is difficult to tell if they are permanently contracted, being 
at one time contracted, and at another dilated. These alterations 
of the pupils are most important signs, particularly when accom- 
panied by the muttering delirium. 

Lesions of motility next present themselves. These consist at 
first principally in subsultus or even spasms, as in typhus fever ; 
indeed I have sometimes hesitated for a little while in my diagnosis, 



472 GERHARD'S CLINICAL LECTURES. 

between the two affections. Paralysis is by no means a necessary 
symptom in the second stage of meningitis. But we have then 
the beginning of another syinptom, rigidity. In the case of a man 
now in the wards, this stiffness could be detected only by careful 
examination of the elbow, but it may be usually very early ascer- 
tained with proper caution. This rigidity differs from contraction, 
which is a more advanced degree of it, and is more rarely met with 
in this form of meningitis. Rigidity is not here confined to one side 
of the body, as in apoplexy and softening of the brain, for the tuber- 
cles are secreted, on both sides of the base of the brain, and, hence, 
the symptoms of disease of the membranes are rarely confined to 
one-half the body, while those of the cerebral substance are as rarely 
extended beyond it. 

These are the chief cerebral symptoms of the second stage of 
the affection. We now pass to another set, those of the digestive 
organs. Vomiting is one of the most constant symptoms of tuber- 
cular meningitis in children, but il rarely continues beyond the first 
stage. Another peculiar and important symptom is constipation. 
In the second of the two patients in the Pennsylvania Hospital, to 
whom I have alluded, the case was at first looked upon by his 
physician as one of simple constipation ; and the true nature of the 
complaint was suspected only when it was found that the symptom 
did not yield to purging. This gives us a valuable therapeutic 
indication, in the treatment of the affection — that is, the {)ropriety 
of purging. The appetite is generally lost from the beginning of 
the affection. The thirst is in proportion to the degree of fever 
present. The state of the pulse may be learned from the case 
of Crane. In him, the bis feriens pulse, of 40 and 68 per minute, 
existing during the convalescence of measles, rose at once to 90, 
and continued at this point till the third stage, when it sank again 
to 85. It was therefore simply febrile in the second stage, and 
irregular in the first and third. It is rarely slows and slowness may 
be looked upon as a good symptom, except in the third stage. 

The other symptoms are less significant in their character, and I 
w^ould merely refer you to the memoirs which I published in the 
American Journal, in the years 1834-35. 

In the third stage, or after effusion of serum, pus, or lymph has 
taken place, the ordinary termination of serous inflammation, to 
which I called your attention in my last lecture; we have a subsi- 
dence of the acute febrile disturbance, the pulse is often preterna- 
turally slow, coma comes on with partial paralysis from the pressure 
of the effusion, which is not necessarily confined to one side of the 
body, and is slow and gradual in its advances. 

I have given you merely a slight sketch of the pathological ana- 
tomy of this affection, as I do -not, in this course, intend to dwell, 
at any great length, upon this subject. The treatment of tubercular 
meningitis, to the consideration of w^hich we now pass, involves 
many important questions. It must vary, according to the severity 
of the actual symptoms, and the circumstance of the existence of a 



TUBERCULOUS MENINGITIS — TREATMENT. 473 

previous tubercular disease. If the patient is in the third stage of 
phthisis puimonaHs, you can of course do Httle or nothing. If this 
be not the case, however, you may, I think, do nnuch. The case 
must be at first treated as one of sinnple meningitis. , Your object 
should be to get rid of the acute inflammation of the brain, 
which increases necessarily the disposition to tubercular secretion, 
and may at once kill the patient. You must not, however, deplete 
to the same extent that would be advisable if there were no tuber- 
cular deposition. You are to steer a middle course. My plan is 
to resort to bloodletting, general and local, unless the development 
of tubercles be very far advanced. I have recourse to general 
bloodletting once, and once only, even in adults. It is an old re- 
mark of writers, that inflammations of the membranes of the brain 
generally bear excessive depletion worse than those of other organs, 
but always tolerate well the local abstraction of blood. Local 
bleeding is to be directed, so long as the patient can bear it, that is 
to say, until he becomes pale, and the flush is gone, whether the 
other symptoms abate or not. After depletion, I was formerly in 
the habit of placing blisters to the back of the neck. I am now in 
the practice of applying them behind the ears. The discharge can 
here be kept up longer, and will act more steadily, and the sore can 
be better dressed ; the patient may be mercurialised by dressing 
these blisters with mercurial ointment. The discharge by the 
blisters I keep up, until the patient is perfectly well. Another re- 
medy is counter-irritation elsewhere than near the head. The feet 
are apt to be cold ; they are to be plunged into hot water from 
time to time, to be clothed with flannel, and rubbed occasionally 
with cayenne pepper. But you are to abstain from further blis- 
tering ; it only serves to create fever, and is generally mischievous. 
Sinapisms may be used, but the surface is not to be vesicated. 

The fiext remedy to be employed is purging. If the patient be 
strong and robust, it answers a very good purpose, and in" a few 
rare cases at once relieves him. But in children, if relief be not 
afforded by one or two purgative doses, it is proper to be cautious 
as to their employment. With children I begin with a mercurial 
purge, from four to eight grains of calomel-, to be followed by a 
saline purgative, or still better some castor oil. Mercurials are 
used by the French merely for the purpose of purging ; of course 
they do not salivate, and, when persisted in, do no good. As soon 
as the acute stage of the disease has abated, you must commence 
with mercurial dressings and frictions of the abdomen. These are 
of most service in the sub-acute variety of the disease. 

I have now detailed you the ordinary practice to be observed in 
the management of tubercular meningitis. To- one or two points 
your attention is to be particularly directed. You must carefully 
watch the moment when it is proper to stop bloodletting, and im- 
mediately after commence the introduction of mercury into the 
system, and continue it until the active period is past. 

After the third stage of the disease is established, and paralysis 

40* 



474 GERHARD'S CLINICAL LECTURES. 

makes its appearance, treatmcDt can do do good. The affection is 
fata!, because the functions of the brain cannot be interfered with 
with impunity. 

Tobercular serous inflammations are not elsewhere so fatal, as 
when they occur in the membranes of the brain. When secondary 
peritonitis and pleurisy destroy life, death usually follows from per- 
foration of the glands of Peyer, or perforation of the lungs. 

The tuberculous inflammations of these membranes, however, 
assume a much higher importance from their tendency to return, 
and even to attack other portions of the body. Besides, they cer- 
tainly favour the development" of tubercles, in cases in which the 
patient had previously presented merely the signs of the diathesis 
which precedes this morbid deposit. For a more complete account 
of this connection, I must refer you to my lectures on pathological 
anatomy. 

The symptoms and treatment of tuberculous meningitis you will 
find detailed in the memoirs which I published in the American 
Journal, in the years 1834-5, as well as in the paper of mv friend. 
Dr. Rufz. 



LECTURE \L 

Peritonifis from cancer of liver. — Acute Meningitis, — Diagnosis — Symptoms — 

Treatment. 

It is my intention, to-day, gentlemen, to continue the discussion 
of inflammations of the serous membranes, with particular refer- 
ence to the subject of m.eningitis. Previously, however, to entering 
upon this latter topic, I shall call your attention to a case of serous 
infiammation, which terminated, a day or two ngo, at the Hospital, 
and hi the post mortem examination of which most of you were 
present yesterday morning. We had, you recollect, acute perito- 
nitis, pervading the whole of the abdomen, the result of a chronic 
disease of the liver. Thi^disease of the liver was suspected, dur- 
ing the lifetime of the patient, there being sufficient evidence of the 
enlargement and hardening of the organ. The nature of the affec- 
tion we found to be cancerous ; rounded deposits having the anato- 
mical characters of vascular sarcoma, were scattered throughout 
the substance of the liver, offering very fair specimens of this 
variety of soft cancer. I shall not now enter into an examination 
of the subject of cancer, but shall confine myself to the acute in- 
flammation of the serous membrane, which was induced by the 
carcinomatous disease. This case of secondary peritonitis exem- 
plifies the law I enunciated to you, at a previous lecture. Serous 
iniiammations, with the exception of those of the membranes of the 
brain, are not very dangerous, unless they occur as secondary to a 



ACUTE PERITONITIS. 475 

primary lesion of an organ, or are connected with a cachectic state. 
This secondary inflammation, which is very frequent in the perito- 
neum, may be either acute or chronic. In the present instance, it 
was acute, and, probably, arose from the cancerous tumours ap- 
proaching the surface of the Uver. Examples of the chronic se- 
condary inflammation of the peritoneum are most frequent in 
phthisis, when they are connected with a tuberculous deposit in the 
serous membrane itself, as was demonstrated to you in one of my 
last lectures on pathological anatomy. 

In the present instance the peritonitis was acute ; it was only 
within the last two or three days of the patient's life that he was 
seized with acute pain over the whole of the abdomen, accompa- 
nied with great tenderness on pressure. A tumour was distinctly 
felt, which I described to you as similar to the pointing of an ab- 
scess, and induced me to suspect the presence of suppuration. After 
the occurrence of the acute pain, the patient sank rapidly, without 
any other of the usual symptoms of peritonitis, as vomiting, &c., 
but his prostration was extremely great. Prostration of this 
character is a striking symptom of the secondary serous in- 
flammation of the peritoneum, and is a most valuable sign in 
leading us to our diagnosis. You have seen it before in a case of 
pericarditis succeeding gangrene of the lungs, and also in the case 
of a black man affected with tuberculous pleurisy. Whenever 
you have sudden and extreme prostration, supervening upon a 
chronic disease, in any of the great cavities, you may suspect the 
existence of secondary inflammation of their serous coats ; but it 
is much more intense in peritonitis than in pleurisy or pericarditis. 
This was the character of the tubercular peritonitis, depending on 
perforation of the intestine, noticed in a preceding lecture; and 
I have, at other times, pointed out to you instances in which there 
was the same kind of perforation into the cavity of the pleura, fol- 
lowing ulceration of the lungs. Perforation is by no means neces- 
sary to the production of these secondary inflammations of serous 
membranes; in the case now before us, the exciting cause was 
the irritation of the cancerous masses in the liver, but just beneath 
the peritoneum. The same disease may occur in the ovaries, 
uterus, and other parts, producing similar results. 

Another example of secondary peritonitis is the affection, gene- 
rally designated as puerperal fever, a term which is now usually 
limited to peritonitis, although some physicians are still in the habit 
of including all febrile diseases of lying-women under this head. 
It is imperative, however, to distinguish between these aflfections. 
The true secondary peritonitis of puerperal women depends upon 
the inflammation of the uterus or its veins, or else upon the irrita- 
tion consequent upon delivery; but it is rendered more frequent and 
more severe by the strong tendency to suppuration, which extends to 
all the membranes and organs of puerperal women, and gives rise 
to the various affections which are sometimes called puerperal fever. 

The anatomical signs in this case were similar to those observed 



476 GERHARD'S CLINICAL LECTURES. 

in the other cases of serous inflammation, which have come under 
your notice just now, from their great prevalence in spring and 
the beginning of summer. Thus, to study pathology, you see how 
necessary it is to pass through seasons and even cycles of disease. 
In these serous inflammations, you see how interlocked they are 
with all other diseases, occurring sometimes as idiopathic, but in the 
large majority of cases as secondary affectiDus; thejfirst class being 
rarely fatal, except when attacking the membranes of the brain. 
Continuing the subject of special serous inflammations, I shall now 
proceed to take up the subject of meningitis. 

Meningitis may be easily confounded with other affections of the 
brain. We had a case a few weeks ago, of a surgical patient, 
affected with disease of the urethra, in which it was with some 
difficulty that we made out, even after death, a satisfactory dia- 
gnosis, the point being settled with certainty, only by the presence 
of a slight quantity of pus. I was called to the case, a short time 
before the man's death, when the only striking symptom was deli- 
rium, which I looked upon as merely the concluding act of life. 
The true nature of the affection was, however, revealed by a post 
mortem examination. We found, first, a bright injection of the pia 
mater, which is characteristic of inflammation, particularly if there 
be no serum present. Injection of the large vessels is not indicative 
of inflammation, but merely of congestion ; the two not usually co- 
existing together — a bright arterial tint denoting the one, while the 
other gives a dark blue colour to the surface implicated. The in- 
jection was in this case spread over the whole surface of the mem- 
brane ; this is generally the ease, although it predominates at one 
portion, either the base or the summit of the brain. Here, the inflam- 
mation was most evident at the summit, involving the faculties of 
the intelligence ; while, in children, it usually occupies the base and 
is connected with a disturbance of the senses. The distinction I 
make here, coincides with one of the leading points of phrenology, 
which allots the faculties of the intellect and of the senses to differ- 
ent portions of the brain. Although I look upon the details of this 
science as still founded only upon the imagination, yet the great 
fact, that the intellect is connected with the summit, and the senses 
with the base of the brain,, is unquestionably true^ and confirmed 
by pathological observations. 

The roughness of the serous coat, the arachnoid membrane, is the 
next point to be noticed in this case. It might seem, that mere eff'u- 
sion of liquid would be enough to characterize inflammation of this 
membrane. This is not so, however; when it is in a healthy state, 
there exists a liquid, which is clear and transparent, but in the early 
stages of real inflammation, becomes altered in quality and deficent 
in quantity. The inflammation is not so much that of the arachnoid 
membrane as of the subjacent pia mater, in the meshes of which 
the morbid products are chiefly retained. True inflammation of the 
arachnoid is of very rare occurrence. In the present case, we 
found pus mixed with lymph in the pia mater, giving a yellowish 



ACUTE MENINGITIS. 477 

appearance to the membrane. The three great features, then, of 
this case, from which we concluded that it was one of acute menin- 
gitis, were the injection of the small vessels of the arachnoid, the 
roughening of this membrane, and the deposit of lymph and pus 
beneath it. 

The consideration of this case offers another point of much 
interest — the connection between affections of the urinary organs* 
and diseases of the brain. Ten years since, my attention was first 
directed to this subject, upon observing a man labouring under 
stricture and thickening of the lining^ membrane of the urethra, to 
my great astonishment, perish suddenly from cerebral symptoms. 
At the Pennsylvania Hospital, two or three years ago, I noticed the 
death of a man from simjlar symptoms of disease of the brain, after 
a few days' illness, who had been previously suffering from inflam- 
mation of the neck of the bladder and urethra. Various writers, 
and particularly f^allemand, have called attention to this subject. 
Dr. Lallemand has dwelt, especially, upon the connection between 
diurnal seminal emissions dependent upon chronic inflammation, and 
the development of cerebral disease. The cases of this character^ 
described by Lallemand, he usually traced to chronic gonorrhoea, 
which, occasioning a thickening of the neck of the bladder, the 
vesiculse seminales, and the ductus ejaculatorius, left the latter in a 
patulous condition, allowing a discharge of semen to take place 
without ejaculation, during the acts of urining or fecating. The 
dependence of cerebral disease upon causes of this nature, is there- 
fore a highly important fact, which will assist you in understanding 
some affections otherwise not easily explicable, for the seminal weak- 
ness, of long continuance, enfeebles the understanding, and, finally, the 
brain is disordered to such an extent, that medical relief is sought for. 
I have had several cases of this character, in which the affection was 
supposed to be connected with a nervous temperament, and was, in 
short, referred to various other causes than the correct one, but, in 
every instance, I was able to make out the previous existence of 
chronic gonorrhoea, producing the condition of the urino-genital 
organs which I have described, and, through this means, giving 
rise to functional cerebro-nervous disturbance. At first this is 
purely nervous, but after it has lasted for a few days it may become 
inflammatory. When the nervous disease is replaced by the organic 
one, you will find that the symptoms become much more permanent, 
and more or less paralysis soon follows. M. Lallemand treats 
these affections by directing his remedies to the urinary organs. 

In the case of the man at the Pennsylvania Hospital, to whose 
death, with cerebral symptoms, I have alluded, we found upon 
examination after death the vesiculse seminales and ductus ejacula- 
torius destroyed; an abscess behind the verumontanum, filled with 
pus ; and the coats of the bladder contracted and thickened. The 
particular history of the case was not taken, but it illustrates finely, 
how chronic diseases of the urethra give rise to affections of the 
brain; and how causes, trivial in themselves, may produce serious 



478 GERHARD'S CLIMCAL LECTURES. 

and fatal functional disturbances. Death, to use the words of M. 
Lallemand, may be the result of a series of illnesses, dating their 
origin from an attack of gonorrhoea ; which is in itself an insig- 
nificant affection. 

From this digression, T return to the subject of inflammation of 
the membranes of the brain. The case of the man Brown, which 
'has been under your notice for some time past, at the hospital, will 
serve as a fair illustration of the subject. We have no example in 
the hospital of acute meningitis but the case of Brown, which is of 
the sub-acute form, being more slow in its progress, and better 
marked in its character, will very properlv serve as introductory to 
the study of the acute type of the disease. This man was taken ill 
with cephalalgia, in the region of the forehead and frontal sinuses. 
We inferred, as we had a right to, that it was not a case of secon- 
dary meningitis, from the absence of any previous ill health. Soon 
after the commencement of the headache, the senses became im- 
plicated ; the sight of the left eve was impaired, and the hearing 
was disturbed with tinnitus, buzzing, resembling: the noise produced 
by a saw, and as the affection declined, it was like the humming of 
bees. These comparisons are the patient's own expressions, and 
were not elicited by any leading question ; they are, therefore, the 
more descriptive of the symptoms. With the advance of the 
disease, there were dulness, sadness, and somnolency, but no delirium. 
There was contraction about the evebrows and the root of the nose, 
forming, as I mentioned when noticing this svmptom in the lecture 
on tubercular meningitis, one of the best m.arked signs of meningeal 
inflammation. The contraction was, in this case, of a permanent 
character, and would have enabled any one, at all accustomed to 
the affection, at once to recognise it. There was no paralysis; no 
subsultus. The inflammation was confined to the anterior and 
inferior parts of the brain, not extending to the summit, as the 
faculties of the intelligence were but little impaired, nor was there 
much lesion of the cerebral substance, for there was neither para- 
lysis nor rigidity. 

After establishing the symptoms, the question starts itself, with 
what affections might this case be confounded ? With very few. 
First, it could not be acute meningitis. The tongue was natural, and, 
although there was some constipation, there was no nausea or 
vomiting; there was no cough; nor was there any unnatural 
excitement of the pulse, and no dreaded delirium or intense excite- 
ment of the brain. The inflammation was then limited to a small 
spot of the brain, for had it been more extended, the pulse must 
have shown it, by becoming unduly excited. The same absence of 
paralysis which showed that there could be but little cerebral lesion, 
•would indicate that the disease did not depend upon large tuber- 
cles, or other chronic tumours of the membranes, for these lesions 
speedily produce palsy. By way of exclusion, therefore, we suc- 
ceeded in localizing the affection, and we recognised meningitis 
attacking the anterior portion and base of the brain. In addition 



ACUTE MENINGITIS. 479 

to its anti-febrile character, its course, which lasted a month, a 
much longer duration than belongs to the acute form of the affec- 
tion, and ils gradual decline, satisfactorily demonstrated its sub- 
acute progress. 

The prognosis was an important point, which came up for 
discussion, at the period of the man's entrance into the hospital. It 
was at first doubtful ; was the meningitis secondary, and dependent 
on the presence of a tumour or tubercles, or the like? After the 
lapse of two or three days, it was clear that there was no chronic 
disease, but that the affection was a mere local phrenitis or menin- 
gitis. We made our minds up to this conclusion, from the evident 
absence of all symptoms of an impaired constitution. The man 
had not been ill before the time of his recent attack, he had never 
called for the aid of a physician, nor had his friends ; I say his 
friends, because in chronic cerebral affections the patient himself 
is often afraid to call attention to his symptoms, and the first appli- 
cation for medical relief is on the part of his friends, as the evidence 
of some decided mental aberration or change of feeling or habits 
is forced upon them. 

The treatment proper in acute meningitis is sufficiently well ex- 
emplified by that pursued in this case. There are certain great 
laws well laid down for the management of this affection, which 
are much more clearly understood than the subject of therapeutics 
in general, owing, I think, to the fact, that close observation is more 
easy in meningitis, from its rapid and well defined symptoms, than 
in diseases of the thorax or abdomen. The following are the points 
to be attended to in treating acute meningitis. 

Bloodletting, in patients who give evidence of tolerable strength, 
embonpoint, and previous good health, is always advisable ; but in 
the acute form of the disease, depletion becomes a measure of abso- 
lute necessity, and if it be neglected your chance of saving your 
patient is but small. Should your bleeding be large or small? It 
is best to take a considerable' quantity of blood at once from the 
patient, if he be a stout and healthy man ; you may thus, some- 
times, immediately arrest the disease. When serving in the Penn- 
sylvania Hospital, I had a case illustrative of the good effects of this 
practice, and of the great importance of a correct diagnosis in 
cerebral affections. A man was brought into the cells, said to be 
labouring under mania a potu : he was a sailor, who had just made 
a voyage from Boston ; he had been drinking to excess, but had 
also been working hard, exposed to a very hot sun. Upon exami- 
nation, I found the signs he exhibited to be not those of ordinary 
mania a potu ; his head was hot, his pulse quick, in short, he was 
in the first stage of acute inflammation of the brain. I bled him 
largely, between twenty and thirty ounces, and he was, I may say, 
instantly cured. It is true, that the next day I directed a slight 
cupping, a purge, and the like, but they were merely by way of 
precaution. Had thjs patient been treated by opiates as a case of 
mania a potu, he must almost infallibly have died. Such cases I 



4S0 GERHARD'S CLINICAL LECTURES. 

have seen treated io this maooer Id hospitals, for so commoo a vice 
is drunkeDDess in this countij, that all diseases of the braio occur- 
ring Id intemperate persons, are apt to be indiscriminately regarded 
as the effects of excessive indulgence in ardent spirits. When I 

was a resident physician in the Aims-House Hospital, a woman 
was brought in with a fracture of the skull, upon which arachnitis 
supervened. She was treated as a case of mania a potu, by a gen- 
tleman who was writing a thesis on this subject ; his mind was con- 
sequently absorbed by this single variety of cerebral afiection, and 
a nnost unfortunate error was commjlted. She died, and opon ex- 
amination afier death, spiculse of bone were fouiid driven in upon 
the dura mater ! 

After you have bled once largely, it is best to limit a repetition 
of general bleeding to cases of individuals of a very plethoric ha '. : . 
In place of general depletion, keep up cupping and leeching, wh . 
if persisted in with regularity, wiU do much good. As to cupp; r r. 
everj^thing depends upon the manner in which it is applied. In , t 
case of Brown, all the cuppings were of service except one, w i: 
the cups were applied to the temples; here it seemed only to s :j- 
ment the irritation — the pressure of the cops very near the 5 7:.: 
of disease causing an afflux of biood to the part, ^he cups, wb ; . 
were applied to the back of the neck, all did good. I do notspeaK 
of cups to the forehead, because no body thinks of using them in 
that quarter. My advice, then, is to cup rarely to the temples, and 
generally to the back of the neck ; leeches behind the ears may be 
employed vrith much advantage ; in this very case, I found leecbirr 
behind the ears of service, when the cupping ceased to do gc: . 
showing the mere change in the manner of abstracting blood tc ; 
of essential importance. Leeching, then, is to be sometimes re- 
sorted to, though cups are generally to be preferred in taking bl: J 
locally, from the ease with which the quantity may be regulate:. 
and the facility with which they may be obtained; but if you £.1 
the patient very excitable, leeches are much more certain than cups, 
and relieve more with the loss of a less quantity of blood. 

In very acute meningitis, you have within your control : 
powerful remedy, and one that is quite as important as any ^: ;:.i 
others — ice to the head. It is to be applied with caution, and .you 
are to judge of its producing an effect by the supervention of faint- 
ness, languor, or paleness of the face. In hospitals, the ice maybe 
applied in a tranquillizing chair, but in private practice, where you 
have no such convenience, a bandage with a bladder of pounded 
ice may be employed for this purpose; you must be careful to re- 
new the application as soon as the ice melts, otherwise the alter- 
nation of heat and cold thus produced may do harm. The use of 
ice I would continue for several days, until there was a decided 
abatement of the acute symptoms. It is a great point in the ma- 
nagement of this disease, to have for the patient proper attendance 
of persons who can control him. For this purpose one, two, or 
three men nurses will be indispensable in private practice, where 



ACUTE MENINGITIS. 481 

those means of restraint are wanting, which are to be niet with in 
lunatic hospitals. 

The next remedy I shall naention acts on the san:ie principle as 
the last, and is intended to produce revulsion from the head ; it is 
the application of warmth and stimulating poultices to theextreaii- 
ties. I was treating a patient some time ago with ice to the head, 
in whom, although, the ice was evidently doing good, it produced 
pallor and languor, and the symptoms abated but little ; upon ex- 
amination, finding the feet cold, I directed warm stockings to be put 
on them, had sinapisms applied, and ordered them to be occasion- 
ally plunged into warm water, which was followed by an evident 
amelioration of the symptoms. Unless you attend to these precau- 
tions, you will lose much of the good that may be derived from the 
application of cold to the head. Upon trifles like this, success in a 
great measure depends, in the management of this affection ; indeed 
in therapeutics the advantage which one practitioner has over an- 
other, depends chiefly upon his attention to minute and seemingly 
unimportant details. 

Although it may be somewhat irrelevant, I cannot here forget to 
caution you against falling into those habits of careless and hasty 
prescribing, which are soQietimes produced by a negligent attention 
to the practice of public institutions. The advantages of hospitals 
are inestimable to one who uses them in a right spirit ; that is, as 
schools of diagnosis, and of the great therapeutic indications. But 
you must remember that in private practice you must carefully 
direct or even superintend in person, a multitude of details, which 
are usually attended to in hospitals by well-trained nurses, aided by 
the system which exists in all well conducted institutions. 

Much of the reputation of Dr. Physick as a practical physician, 
depended on a strict attention to these minuter points of detail, 
and he had, therefore, often better success in the management of 
even medical cases, than persons who were perhaps more familiar 
with pathology, but not equally attentive to these particulars. 

Purging is a remedy which has been almost from time immemo- 
rial adopted in the treatment of acute inflammations of the brain. 
The saUne purgatives combined with senna, or a mercurial purge, 
are those generally employed. I prefer a mercurial purge, as it 
serves a double object, by acting on the liver, and preparing the 
way for ptyalism, if it should afterwards become necessary ; it is 
besides a good preparation for the saline articles. I w^ould begin 
by ten grains of calomel, followed up the next day by a dose of 
salts and senna ; should the calomel not purge, it will salivate, which 
is not to be dreaded. After, at least, a single mercurial purge, you 
may give doses of senna and salts, — a robust patient will require 
half an ounce of each ; these, by inducing serous discharges from the 
bowels, will have a derivative efTect. Afterwards your object should 
not be to produce violent purging, but to keep up a moderate loose- 
ness of the bowels. 

Should the delirium not yield to depletion and purging, these 

41 



482 GERHARD'S CLINICAL LECTURES. 

remedies should not be continued after the strength of the patient 
begins to decline, but you must now have recourse to mercury in 
small doses, and to blisters. Mercurials, like tartarized antimony, 
act as antagonists to inflammation, and may with propriety be em- 
ployed in the second stage, or in the sub-acute form of the afl^ec- 
tion. They would have been highly appropriate in the case of 
Brown, in whom we should have prescribed them, had the disease 
not yielded in the first instance to the local depletory treatment. 
It is best to continue the use of mercury until ptyahsm is produced. 
By efiecting this, I have succeeded in curing a large proportion of 
the cases which have occurred in my w^ards of the hospital. An 
interesting case happened last summer, which, perhaps, some of 
you may recollect. It was that of a young man who had been a 
cJerk at Mobile, and who on his way to Philadelphia, by the Mis- 
sissippi river, had been taken ill with fever and delirium at Cincin- 
nati, from which he recovered with difficulty. He came to Phila- 
delphia not quite well, having still some symptoms of cerebral 
disease. He was taken ill again and brought to the hospital. He 
was then in a state of high cerebral excitement, being occasionally 
rational, and relapsing again into delirium; throughout the night 
he would be in a state of great liveliness, loquacious, restless, 
with his senses considerably excited. From the history of the 
case, I concluded it to be one originally of acute meningitis, which 
had now become chronic, and began the treatment of it with blisters 
and local depletion, but the delirium did not yield, until a mild mer- 
curial course was presented. Another case I may mention was 
that of a young sailor, who was taken ill under circumstances which 
I do not now recollect. He had pleurisy first, and afterwards 
meningitis, and the disease did not abate till after a mercurial 
course. The symptoms w^ere not the violent delirium of the last 
mentioned patient, but mere stupor, dulness of the senses, and con- 
stant disposition to throw his head strongly backwards. Neither of 
these cases was dependent on the presence of tubercles or other 
chronic lesion. 

We come next to speak of blisters, which, it might seem at first 
sight, would be proper at an earlier period of the aflJection. This 
is not the case, however ; in the first stage they seem only to irri- 
tate, and decidedly augment the extreme agitation and violent 
delirium ; they should be delayed till the acute symptoms subside, 
when they may be applied over the occipital region, extending to 
the back of the neck. They are to be rarely applied over the 
whole scalp, where they give great pain. The same law that 
regulates the employment of leeching or cupping is applicable here ; 
the blisters do more good at some distance from, than immediately 
over the inflamed portion of the brain ; when the disease is more 
chronic, it is often useful to keep a blister discharging behind each 
ear, as I have already advised in the treatment of acute hydro- 
cephalus. 

Caustic issues or incisions over the fontanelles have been recom- 



MENINGITIS. 483 

mended in chronic meningitis, but as they are very inconvenient, 
they have not been generally used, though I see no reason why 
they should not be employed in certain cases, especially where there 
is reason to apprehend that the disease has followed an injury of the 
head. 

The plan of treatment which I have given will succeed in cur- 
ing the majority of cases of acute meningitis. If, however, the 
affection should not yield, and passes into the chronic state, the 
patient remains necessarily more or less insane, and is apt to sink 
into the third stage of insanity or dementia. He becomes utterly 
incoherent, and the case usually terminates in a very curious but 
totally incurable variety of paralysis, called the paralysis of the 
insane. 

In the beginning of this kind of insanity, when the appearances 
of active infiammaiion have in a great degree subsided, cold affu- 
sions upon the head, repeated several times daily, mild laxatives, 
a sparing diet, abstinence from all excitement or exposure to the 
sun, with gentle exercise, prove the most useful remedies. In short, 
the treatment must be extremely mild, but persevere while a hope 
remains of saving your patient from the worst species of insanity. 

When acute meningitis is fatal, the patient generally dies at the 
end of the second, or in the third stage of the disease, or he may 
die from meningeal apoplexy. I have twice or thrice seen a patient 
in the Aims-House, labouring under meningitis, become suddenly 
comatose, with stertorous breathing and loss of power of the limbs. 
The symptoms were those of apoplexy, arising from effusion of 
blood, not into the substance of the brain, but on the surface of 
both hemispheres into the membranes, which, from its pressure, 
is therefore necessarily fatal. 

Whether the inflammation of the membranes of the brain be 
acute or not, as soon as the third stage, or that of effusion of lymph 
or pus supervenes, the delirium becomes less violent, the disturbance 
of the senses is succeeded by a total abolition of them, the patient 
neither seeing or feeling. There is a gradual supervention of para- 
lysis ; sudden dilatation of the pupils in place of alternate contrac- 
tions ; and there is usually, but not always, strabismus. This stage 
is necessarily fatal, there being no possibility of a recovery. 

To recapitulate briefly the course of my remarks to-day — you 
have had your attention called to the anatomical characters of 
certain serous inflammations, and after tracing the connection 
between cerebral affections and those of the genito-urinary organs, 
I have entered at length into the treatment of acute meningitis, 
basing my remarks upon a case of the subacute variety which has 
been lately under notice at the hospital. I have not gone into more 
details of the symptoms of acute meningitis, waiting till they present 
themselves to our notice, which, from our knowledge of the course 
of these affections, must be the case during the summer. The sub- 
acute variety is the only one which I am now able to demonstrate, 
by reference to a case actually under your notice. 



454 GZ5HAILD-"S CLESICAL LECTTEES. 



LECTCJRE TIL 



Cliraim: memngitig. — Ap<^i^> — Faraivas ai cae msane. 

At my last lecture. I continaed tfi.e subject of izmannnatiocLS of 
the brain, dwelling particalarlv upon that of aeote meningitis^ whicti 
I was ai:Ie to iilastrate bv a case of the sub-acute iorm of the 
afieetion, at that time under vour notice at the hospital I merelT 
alluded at the time to the subject of chronic meningitis, without 
entering into it at any lengthy and I, therefore, propose now to saj a. 
few words upon it, as it properly belongs to this period of my course. 
We have a large number of cases ef this afieetion in the wards of 
the hospital. I shall select the best marked of them,, that of 
"Crweiler, a German, to whose history and symptoms I ^ail briefly 
call your attention. This man, two or three years ago, having^ 
previously enjoyed good health, received a blow on the head^ the 
efiects of which, at the time, were not very seriously felt. He 
suffered slight headache, pain, &c., which however soon abated. 
But, after a lapse of time, the powers of his mind began to fail, and 
be became, finally, entirely deranged, and in addition to this disor- 
der of the intellect, paralysis is gradually supervening-. This latter 
symptom, as yoa may have observed in the hospital, is a very 
common acctMrnpaMment of insanity, chiefly of dementia ; it i^ 
kowever, often niet witk in persons in whom insanity is not yet 
developed, the fanctioi^ of motility being attacked before the 
intellect is much impaired. The disease is, tker^ofe, efiea to h& 
recognised at first by the mere disorder 'm the-pom^ES^ tif miBmemteatt^ 
and may o rdinarily be detected as follows. Slight symptosis-frf'aieBtaL 
aberration are presented, often not well marked, but, agai^iafBl-j 
becoming strongly characterized, and runmng ii^» tbe wwHfc li^rse 
of madness — incoherence. The organs of lococnelreB lieceiaealsG 
afected, the first symptoms being a fadure in the power of walking; 
but feebleness of the upper extremities does Ewt often .show itself at 
first : a hobble or limp is noticed, generally, at first, on one ade of the 
body only. Other changes then take place, the upper extri i : 
becoming involved, the tkce slightly distorted, the tongue is pr ; ■ ._ t _ 
with difficulty, and the speech thick: these symptoms, howeve.-, 
are often indistinct at first, with the exception of the fai!-:'r :z :he 
power of walking, which always shows itself. The 37 
the most part, gradually bet slowly advance, scarcely c-c retro- 
grading. If the patient is insane when the partial paralysis appeal^ 
the afieetion is nearly always fataL Dr. Cal'meil, who was coa- 
nected with the lunatic hospital at Cbarenton, near Paris, coa- 
sidered it always fatal ; and my own pro^noas accords wery nearly- 
with his opiiiiQQ- It is somewhat singular that this disease is moeh 
more frequent in men than women ; althotigh yery camocioH. s£ the 



PARALYSIS OF THE INSANE. 485 

Bicetre and Charenton, it is comparatively rare at the Salpetriere, 
where none but women are admitted. 

In the diagnosis of this affection you must not, however, be too 
confident; it is necessary that the cerebral symptoms should be 
permanent, and not merely the slight disturbance of brain which 
occasionally results from disordered abdominal functions. If you 
are not quite sure, therefore, watch the patient for a little while, 
and the case will become clear. 

I shall not now enter at length into the pathological features 6f 
the affection, merely bringing before you two cases that came 
under my notice some time ago. One was of a gentleman, who 
died about two years since; he had been hurt by a fall, from the 
consequences of which he seemed to have recovered ; but two or 
three years subsequently his walking began to fail, soon afterwards 
his mind, and a short time only passed after the development of 
these symptoms, before he died. On examination after death we 
found the membranes of the brain universally thickened. The 
other case was that of a man, who had been a master of a vessel in 
the merchant-service ; just previous to his attack, he had been suffer- 
ing from a soreness of throat, which improved but little under a treat- 
ment consisting chiefly of local applications; symptoms of disease 
of the brain soon appeared, and the man entered the Pennsylvania 
Hospital. At this time he had incomplete paralysis of the lower 
extremities and of the left arm, with painful deglutition ; these 
symptoms went on slowly, but finally destroyed the patient. After 
death, we detected a slight thickening of the membranes lining the 
ventricles, and were astonished to find how little the medullary 
substance of the brain was affected, and that the cortical substance 
was merely in the normal state. 

Treatment in chronic meningitis is available only when the func- 
tions of motility are not impaired, and those of the intellect alone 
are affected. The mode of treatment to be resorted to, consists in 
a regulated diet, blisters to the nape of the neck and behind the ears, 
and cold affusions twice or thrice a day. Although I cannot affirm 
that I have entirely cured any patients labouring under actual 
paralysis, I have certainly, by the plan detailed to you, restored 
several in whom the disease had proceeded no farther than the 
affection of the mind. The patient Urweiler is much better, speaks 
with greater ease, and has obviously more strength in the limbs. 

The next disease of the brain which I shall notice, offers, at this 
time, several cases in the wards of the hospital, and will be often 
encountered by you in the course of your practice — I mean apo- 
flexy. Of the cases in the hospital, one is a recent one, and two, 
in the black wards, occurred as far back as a year ago. The 
term apoplexy is often used very indefinitely. It is applied to four 
different pathological states : 1st, true apoplexy, or hemorrhage into 
the substance of the brain or its membranes; 2d, simple congestion, 
or preternatural fulness of the vessels of the brain ; 3d, serous 
apoplexy, in which the brain is oppressed and its functions impeded 

41* 



486 GERHARD^ CLINICAL LECTURES. 

by a large serous effusion ; 4th, nervous apoplexy, in which many 
of the symptoms, such as loss of consciousness. &c., are developed 
without any appreciable organic lesion. I shall here employ it to 
signify an actual hemorrhage into the substance or beneath the 
membranes of the brain, excluding mere effusions of serum, all cases 
where there is no organic lesion of the brain, as well as those in 
which mere congestion occurs, an affection which is most frequent 
during the summer season, and at the close of the winter. These 
cases are all confounded with true apoplexy, and indiscriminately 
classed under the same name ; sometimes, indeed, when no one 
function of the- brain is disordered, the term apoplexy is given to 
sudden deaths. A man will fall down dead, perhaps, with some 
comatose symptoms from disease of the heart, and his death is at 
once referred to apoplexy; whereas, genuine apoplexy almost never 
causes instantaneous death. When the case terminates fatally, it 
is usually after a lapse of some months, from paralysis. It some- 
times proves fatal in the course of a few minutes, or half an hour; 
but in these cases there is usually blood effused into the ventricles, 
and it is not common for it to terminate before the end of several 
hours, even when most severe. The exceptions to the rule, that 
sudden death does not follow apoplexy, are indeed so rare, that you 
may pretty safely pronounce an instantaneous death to be indepen- 
dent of this cause. These very sudden deaths are usually owing 
to diseases of the heart, although in some of them no organic 
lesion whatever can be found of any organ.* There was an ex- 
ample of this sudden death a few months since at the hospital, in a 
patient who was labouring under a chronic disease of the heart, 
who died during my visit. 1 found him in his ordinary condition, 
and had just left the ward, when I was suddenly called back and 
found him dead. 

The anatomical characters of apoplexy are easily ascertained, 
and maybe divided into two great varieties — in the first and most 
common, the effusion of blood takes place into the substance of the 
brain, in the other it takes place into the membranes. Any spot in 
the brain may be the seat of the hemorrhage, but it is generally 
the thalamus of the optic nerves and corpus striatum. The blood 
is sometimes poured out in such quantity as to break into the ven- 
tricles, and even force asunder the septum between them, so that 
it presses upon both hemispheres of the brain ; but it is generally 
confined to a single spot, on one hemisphere. 

The character of the clot is always the same ; it consists of a 
mass of dark coagulated blood, surrounded by the tissue of the 
brain, which is, to a certain extent, ecchymosed and softened : this 
softening may be either the effects of previous disease, or the con- 
sequence of the apoplexy. Dr. Rochoux, who observed at the 
Bicetre hospital, thinks that apoplexy ahvays depends upon the 
previous existence of local softening in the brain, the hemorrhage 

* Memoir of Dr. Louis. 



APOPLEXY. ^ 487 

afterwards taking place in the diseased portion. My own, and the 
general opinion is, that in the large majority of cases, softening of 
the brain around the clot is a consequence of the pressure from the 
blood thrown out, the hemorrhage itself depending upon a disorder 
of the circulation. The cause of the deranged circulation is some- 
times hypertrophy of the heart, which increases the impetus of the 
blood ; at other times, the cause is to be sought for in a diseased 
state of the arteries and capillary vessels, either of the brain itself 
or of the whole system. But although the opinion of Dr. Rochoux 
is too exclusive, it is by no means unfounded, for there is a certain 
if not a large proportion of cases, in which the evidence is deci- 
dedly in favor of previous lesion of the cerebral substance. These 
rases are somewhat analogous to the hemorrhage which follows 
diseased uterus, or the advanced stages of pulmonary tubercles. 

After the clot has been some time in contact with the substance 
of the brain, it is in a measure isolated by the formation of a cyst 
which completely surrounds it. It is afterwards gradually absorbed, 
absorption taking place in the following order: first, the serum 
disappears ; secondly, the colouring matter ; and, thirdly, the 
fibrin of the blood. After a lapse of some months, the cyst only 
remains, in one of two conditions : — it is either entirely hollow, 
and lined with a new serous coat, or a little cellular substance oc- 
cupies the old seat of the apoplexy, and then the cyst is either imper- 
fect or entirely obliterated. In one of these two forms the parts 
are invariably found. 

This succession of lesions has been perfectly well illustrated by 
the cases which have been just now under our notice, for there are 
particular symptoms, corresponding to each stage of the disorder. 
One was that of the old woman, in ward No. IV., in whom there 
was a complication also of softening of the brain. For, in addi- 
tion to the paralysis which follows hemorrhage, we have strong 
contraction of the flexor muscles on the paralysed side, so violent, 
that pain is given to the patient by an attempt to extend them. She 
had been well, we learned, two weeks before the attack, which 
determines it at once to have been of an acute character. The 
next point would be the manner in which it occurred, — was it 
sudden or gradual ? This we cannot settle satisfactorily, from our 
inability to ascertain the previous history of the case. 

The paralysis might arise either from acute softening or apoplexy, 
and as the distinctive characters of these two affections chiefly 
depend upon the abrupt commencement of the latter, and the more 
gradual progress of the former,, it is evident that we cannot make 
a positive diagnosis. The rigidity which is so striking in the para- 
lysed side of the body, is produced by softening, but this softening 
may be merely secondary to the hemorrhage. It does not take 
place in the beginning of apoplexy, it follows when the parts around 
the clot become inflamed ; whereas, in inflammation of the brain, 
the numbness, stiffness, and rigidity follow in rapid succession, from 
the onset of the affection, and precede perfect paralysis. There is 



^SB tES^WSSBm flmnw mAn. ira^r rmnagR 

Himfter feitt shGDwh^ tties asfflsE ttD&E mwypk^v.i ItiEttii^. tte esSteitt off 
lim parahss. whiiiii is TaislyaD^TSECt itj mfmmnmtDrv tit Tunr^infenxT- 

jffi II im^fs issbxEt osmaTiasii, sttaEkhig :tte sirmintt uf ilie drmm, wim 
hs^FB rteiiriurri nf e uidt^ ht fcsE viotem xiimrHnfer:. Itee mini; isiiw 
aiwHx^ EnmprflTnissiJ;; xff 'UnwD]v^ tte ii^^ tt tte .irram. ^nor liXE^ee 
Blteratiiffi nf te rniiutiniK nf motmn. :ffiB sinsutuis, ^isns. Ms,,. 
smi ties s^iit k Hfectsxi. du;. ss tTESir ik iiir* uaraMgsffi ;ict fiisst, ^nm 

j^imtiffiT pDim nf snn^ jmpnriancs, im TOEaiirim^ ^FB^wmm off 
Hpnpte3ry, ik ctD ndisiii^msh lit, iiiniiT^ ttiBS iiTsst few tuoins Ttf ite 
aSsciioTi, drram rmsTE uni^sslini] nf ittes drrBiu. ICtik s tou m *sfflw 
Hi ifiist, iffiBsaffiir liffi krpas nf xl few" thnircB:: doxtt -ttEBS ai3e«nTiiBe Tsasm- 
liariies aiiniil liissB Edfentions. ^'hiirh. if iJti}^2k HtEsnttBii Tii "wiL 
S2r\^lD limw lti£ iuee nf ristmiiiam. Ir. tree Inst piaiSi. 3j'fE3r:tTe^ 
£Tst few mmui^ nf ttee Ib^ ni' cniffiGiiusre^. wrniETi isimlkoBEHirs 
at tte n^mniig nf iintii, tlBarr .k qmTaHsK ilf me subs ntniBS, iie 
capnpfeffisx. Ihi Taai^astiuii, im tties ntiffir dmiiii. rtasm iffiscHTCsk ^awar 
immi^jfetegmTahssiE nf sitter. i)iitlteT^k^3iB3r^ smMe niffiiiutfix^ 
(dF imntimi lin iintii. H^aracoiK mtstiiteii wiittli SBnbter bt^ iinl sod 
cnmmnnk nf tiiL' sante TnL trabii nf iroity ^bbb tiusee wair sufei Tnnn 
acii^^ iinngsstiDT*. sd tlmt tiiff pisttin-m :is ^liniK sufimEn: n rarmiBB 
3^011 tt BnspfiKt tiiE ca]^ in iss cm^ssiinri. A niise iiia;giii}a£. hi ttiiE 
iBSgmnmg nf tlBS twD Hfeminiifi, BB.nni vsry irm^xtani :: it:sTm^^'HTB3r 
tiiey imv£ aiivaTirsati bs^rmEd .ties fest sti^s, tttimittdKEnnn^ nfomB- 
^sgiKiicE, :i^ T3^aTik tte ttiasntiTBaitt. ttn cdktiT^nkii dffi^t^Assm ttis 
:twx). Wjh s^fsr^v iia^, nfteriw tiBs symntmiK i3f iiMs oof imiss roi^ 
TR?ps. riifficutt inTsatiiing. tm^ssisnise nf tte^^^sKeteaaTttiK^fesis.itoL., 
iui: niiie CDUTSE nf iisatmsn ! ss li> ijs tnoij^t nl.iie HnijA^k iisnernry.. 
Sim alfer tlBS sills idsni:^ nf ItE^ iinnisjdia;& ^yirmtnins iisss^wninL 
^thirn fer nfereii tie sane ciiiiTaEBsi. itemaim il -vioESiy nrfeTsnupimi 
flfttTEHtnffint. 

II isH/VE Ht-Rsany xiliiifeii tr liiasis; nfsHiffiim} nf sariraniiL itiE dusam 
"wiiLeii Hm smrmiimes cnniauiumri i^ilt npnpiis^- ifrn^^ ^iBammnnxBEGa. 
imd. ai^ tsrmen shtdie apffpery-^i; temi niter i^ail li> xennteilEB 
pii^ani^ nf EniKatnsB F^Tniitnns. wilnnitt HemnrrrraiK. TTtiE :ffl3TDiEE 
apontexy Tiffiry ncnnT from, ite sffisinTi ni sarinr. isaiesaatij lie Liresm- 
joranes. nr mtC' tte ^QsntriueaE nf :tre iiram:: in tlee iatBar ue^a, ^ti he 
unl infremisnt m manin a qnitu. Hifli iam> irn samie ii^[^^ off m 
niiTDnit i:iiaTani33T. ITiB^ ttsraas. .rtmvws^voax, iif innnati^t ^Anaqptmrs 
Jrnm 3S3tdik eJSisimi m^ xif -thise nEnurESHiBS;, asxispi ottt itiK odhsss ie 
i33]ffii)Tai liiseffiEEs nf si^^ disHinssis. 

Smiifen cnnm. sniirefy iiuifnKTiiiEnitTd^^ nffiaaaasodfttelirBam 

smTBStiinas appeals, as tii£ cansransTiiae nf n bt^svohje niimnG: nfflsase 
ni varroiK wscera. nr evuii nf ii^te aiKsmiL, uihbt; EimnmsiaiEasE 
cabaiaisd iimt a iitlte ti- pnzafe ttiE pT-aniinmEi. A co^ uf tiiffismti 
DECirn^ tiffi iwrateT i»2tmf^ to;, im my "\;^faTik nf itie Hisprtal. Jk 
sfiamaii ivhr imd ifiserj sxpisEsrlttD giastuimTiMipffiyHniliiiaii ccniiiTHiiBsti 
a nseas nf ;tii£ ii jvs: m tisMmi UntiEss. nf -mti'iz^: is: iimr-w^l^ 



APOPLEXY. 489 

marked evidence in a pale-yellow, jaundiced skin, came into the 
ward complaining of neuralgic pains in the feet unattended with 
fever. He had no symptoms whatever of disorder of the brain, or 
of the thorax ; nor of the abdomen, except those indicative of a 
diseased liver. After remaining for a short time in the hospital, he 
was one night found with comatose symptoms, stertorous breathing, 
&LC.J having been seen, only an hour before, walking across the 
ward for a cup of water. I saw him only an hour before his death, 
in a state in which it was exceedingly difficult to arrive at a correct 
diagnosis; I, however, came to the conclusion that it was not apo- 
plexy, from the fact of the symptoms not being limited to one side 
of the body. An examination after death revealed no alteration 
whatever of the brain, except a very trivial quantity of serum 
beneath the arachnoid. He had, therefore, coma, loss of conscious- 
ness, and stertorous breathing, during life, without any lesion of 
the brain. 

Symptoms of the same character occur from the effects of heat 
upon the nervous system, during the warm season. During the 
intensely hot weather of the summer of 1 830, 1 witnessed the opening 
of the bodies of twenty or thirty persons who' died from this cause ; 
we found no organic disease of the brain, but merely a slight con- 
gestion, such as is observed in other acute diseases, which it would 
be idle to set down as a cause of death. These were the appear- 
ances in those only who died suddenly of exposure to heat; for if 
lime elapses for reaction to come on, inflammation of the brain may 
take place, but it is then a secondary affection. 

The other two cases of apoplexy, occurring in the hospital, to 
which I shall direct your notice, offer varieties of the disease dif- 
ferent from the first described. They were black men, who 
entered the wards in a state of complete paralysis of one side of 
the body, one of them scarcely able to speak. He could articulate 
but the monosyllable no, which he answered to all questions what- 
ever that were put to him. He seemed conscious of the ridiculous 
nature of this invariable answer, but could not increase his voca- 
bulary for several months, when he was gradually able to pronounce 
the shorter words, and now speaks very well, although there is 
still paralysis of one side of the body. In the other, the speech 
was merely thick, but his mind remained tolerably clear. They 
continued in this state for several weeks, and as the process of the 
absorption of the clot advanced, the intelligence brightened, but the 
paralysis remained. These were cases of hemiplegia, one side of 
the body being affected ; that, opposite to the side of the brain, in 
which the hemorrhage occurred. This latter conclusion we drew 
from a law of pathology to that effect, which is almost without an 
exception in its operation. There may be one, two or three ab- 
normal cases out of a thousand, but, in making your conclusion, 
you may safely leave them out of the estimate. 

As the next consideration, in the study of the diagnosis, we had 
not only paralysis of the lower portion of the body, but also of the 



490 GERHAED'S CLINICAL LECTURES. 

upper extremity, and the muscles of the face, with disturbance of 
the intellect and senses, establishing, of course, the seat of disease 
to be the brain. The stiffness of the limbs was gradual in its pro- 
gress, caused by inflammation around the clot: but the paralysis 
was, at the time of the patient's entrance, perfect ; and the mouth 
was drawn towards the side which was not paralyzed, which is the 
reverse of what occurs in cerebral inflammation where the paralysis 
is acti\-e, that is, the mouth is drawn towards the palsied side. Our 
diagnosis and prognosis were at once made out ; there was a 
hemorrhage on one side of the brain, and it was incurable, because 
the paralysis was complete, in which cases it is for life, the only 
chance of recovery being when it is incomplete. 

The liability of apoplexy to return is a matter of notoriety, and a 
point perfectly well understood in the world: you should, therefore, 
in all cases where it has once occurred, be on the watch, looking 
for a recurrence of the hemorrhage, which nearly always takes 
place near the same spot, between the thalamus and corpus stria- 
tum. 

The cases under notice were not fair specimens for testing the 
treatment proper for the paralysis of apoplexy ; but some of you may 
recollect a case, which occurred last summer, of incomplete paraly- 
sis in a woman, which yielded entirely to treatment in a week. Dr. 
Foville of Rouen, explains the difl'erent success of the treatment in 
paralysis from hemorrhage by the occurrence in some cases of an 
actual rupture of the fibres of the brain, while in others these fibres 
are merely separated by the effused blood without being torn across. 
I am myself inclined to this opinion, and believe that the medullary 
fibres are actually broken in most cases of complete hemiplegia. 
The routine of treatment in apoplexy is simple and familiar to all 
medical men. Very free bleeding is of course indispensable, in 
all patients, who are at all plethoric: if of a pale, anemic 
complexion, it is to be practised with some reserve. Purging, foot- 
baths, and cupping are to be resorted to, although the latter is not 
of the same value here as in meningitis, where it is our sheet- 
anchor. I here indicate merely the general outline of treatment 
to be pursued in apoplexy, not entering into any details on the sub- 
ject. In regard to depletion, I may remark that it is a point of 
some delicacy to determine how far to carry it. My rule is, to 
continue depleting until the circulation in the vessels of the head is 
lessened, which is to be ascertained as well from the appearance of 
the eye and countenance as from the pulse. Purging I also push to 
some extent : but you must be careful not to purge too violently, or 
that state of chronic softening of the mucous membrane of the 
intestinal canal, which was mentioned in a previous lecture as a 
frequent accompanimient of the exanthemata, may occur; it is 
a most unpleasant complication in paralytics, who rarely resist a 
diarrhoea long, however much thej^ may have been previously bene- 
fited by purges. Blisters, setons, and issues, are all used in apoplexy, 
bat with indifferent success, although the keeping up of a discharge by 



ACUTE SOFTENING OF THE BRAIN. 491 

these means, is excessively useful in chronic meningitis. If, how- 
ever, the apoplectic symptoms are pertinacious, these remedies may 
be tried once or twice, and continued according to the effect pro- 
duced. 

If you are called to a patient suffering from apoplexy, after the 
full mischief of the hemorrhage is produced, and perfect paralysis 
is established, it is your duty to announce at once to the friends of 
the patient the impossibility of his ultimate recovery, explaining to 
them the nature and amount of organic lesions existing in the brain, 
and the impossibility of an entire cure. 

The last point in the treatment of apoplexy to which your attention 
must be directed, is the sores which are likely to occur about the 
sacrum, trochanters, &c., if the patient is obliged to keep his bed for 
any length of time. The bladder is also apt to become diseased in 
this affection, and you must watch and guard against too long a 
retention of the urine. 

I shall conclude this lecture, by saying a very few words on the 
subject of acute softening of the brain. This affection is dis- 
tinguished from apoplexy, by the presence of fever, dizziness, and 
vertigo from the very beginning; while you will rarely observe any 
febrile movement, in cerebral haemorrhage, till some time after the 
effusion of blood has taken place. The numbness of the limbs, 
which is a common symptom in softening of the brain, comes on 
very gradually, and, although the intellect is feeble from the first, 
yet the impairment of its faculties is comparatively slow in its 
advance, there being at first, and for some time, merely dulness, and 
no active delirium, afterwards. In a black man, under my care, 
four years ago, at the Pennsylvania Hospital, the delirium assumed 
the character of well-marked mania. This maniacal delirium is 
different from the more active kind occurring during the inflamma- 
tion of the membranes and cortical substance of the brain. It is 
an affection which rarely occurs, except in the young and middle- 
aged, and is not to be classed with chronic softening of the brain, 
which is a sort of necrosis, or gangrene of this organ, and is met 
with only in old persons. In this latter disease, there is no active 
febrile movement whatever, the patient advancing, with unfailing 
certainty, from bad to worse, to death. The affection is dependent, 
according to Dr. Carswell, on a cartilaginous condition of the blood- 
vessels. Dr. Rostan, of the Salpetriere Hospital, observed the 
disease on a large scale, and has published a monograph upon the 
subject, in which he states it to be beyond the reach of treatment. 
In this country, I regret to say, that our experience does not mate- 
rially differ from that of Dr. Rostan. 

The acute softening is, then, nothing but cerebritis or inflammation 
of the brain, while the chronic disease is almost the reverse of 
inflammation. As the latter affection is incurable, and occurs 
exclusively, or nearly so, in very old people, it is of little importance 
in a therapeutic point of view : but the acute softening may be cured 
in many cases if treated vigorous from the first. This treatment is 



492 GERHARD'S CLINICAL LECTURES. 

similar to that recommended for meningitis, except that general 
depletion should be much more insisted upon ; local bleeding being 
of comparatively little value, at least in the early stages of the disease. 
The pain is often so slight in this disease as to lead the observer into 
an erroneous belief, that there is but little the matter with the 
patient, until the paralysis or decided mania supervenes. Hence a 
numbness of the side, if connected with disagreeable sensations in 
the head, or many signs of vascular congestion, ought to be treated 
with energy. 



LECTURE VIII. 

Apoplexy and inflammation of the brain (continued). — Functional diseases of the 

brain. 

I SHALL, this afternoon, again call your attention to some organic 
and functional diseases of the brain. It was my intention to have 
confined myself to the subject of functional cerebral diseases, but, 
owing to the termination of one of the cases of apoplexy, followed 
by acute softening of the brain, noticed in the lecture on these 
subjects, at the post mortem examination of which some of you 
were present this morning, I am induced to recur to the topic. 
The impossibility of understanding the subject of organic diseases 
of the brain without a knowledge of their pathology, is well ex- 
emplified by the case under consideration, while, on the other hand, 
you have seen how exactly the phenomena after death coincided 
with what we were able, from the symptoms during life, to announce 
would be the case, and how entirely the prognosis as well as diagno- 
sis has been confirmed by the result. 

This case was that of Fisher, one of the blacks alluded to in 
Lecture VII. He entered the hospital a short time after having 
been seized with loss of consciousness, and other symptoms denot- 
ing an attack of apoplexy. The inflammation, excited by the clot 
of blood thrown out, induced an inflammatory softening of the struc- 
ture of the brain, which seems sometimes to be a useful process, 
and promotes absorption of the clot; it occurs from the same cause 
that gives rise to inflammations wherever a foreign substance is 
present in any portion of the body. The train of symptoms, announc- 
ing the existence of acute softening of the brain, we treated by cup- 
ping, purging, and a regulated diet, not using general bleeding from 
the enfeebled condition of the patient. Under this treatment, he 
was slowly getting better — he could crawl about the ward, and 
could articulate short sentences, when yesterday he was seized 
with a fit of convulsions, as the nurse termed it, and was found by 
one of the resident physicians in the state of coma, with dilated pu- 



APOPLEXY. 493 

pils, &c., which soon terminated in death. The examination after 
death, this morning, explained the occurrence of these symptoms. 

We found, first, the remains of the old apoplexy, which had taken 
place a year ago, probably a few days before the man's admission, 
as nearly as we could gather from his imperfect account of himself. 
The disease had occurred at several different points of the left hemi- 
sphere of the brain. The left corpus striatum was shrunked and 
shrivelled up, and unnaturally hard and indurated. On incising it, 
at the depth of the eighth of an inch, a well marked cyst was found, 
rather more than an inch long, and half an inch broad, lined with 
the usual serous membrane, which was not quite complete; a part 
of the walls of the cyst were composed of loose cellular substance, 
filled with an opaque liquid. This serous membrane, lining the 
cavity, was not a true but an adventitious serous membrane, or ra- 
ther sero-cellular, such as is thrown out in inflammation of the 
pleurce and pericardium. 

I have already told you, in a previous lecture, that these cysts 
are left after the complete absorption of the clot of blood. The evi- 
dence that they really arise from this cause is entirely complete ; it 
might, indeed, be inferred from the facts which relate to the cases 
just pointed out; but if you are not able to follow every step of the 
reasoning, I would refer you to the work of Dr. Rochoux. The cyst 
in question occupied one of the usual seats of cerebral hemorrhage. 

In. addition to these morbid changes, there were the traces of a 
large apoplectic extravasation on the side of the brain, the confor- 
mation of which was obviously altered by a depression on the 
middle lobe of ttie left hemisphere, just behind the temporal muscle, 
quite unconnected with any alteration of the bone. 

The membranes adhered very closely to the substance of the 
brain, and beneath them was a partial softening of the medul- 
lary substance, which was of a light yellow or cream colour to the 
depth of about an inch, with complete destruction of the cortical 
substance in a space of two and a half or three inches square, that 
is, in the whole extent of the depression, necessarily rendering that 
portion of the brain totally unfit for use. At the posterior part of 
this softened portion was an imperfect cyst, more than an inch 
long, the walls of which were formed by a loose cellular substance, 
extending to the distance of from a quarter to a third of an inch. 
Near the centre of the same hemisphere, about an inch from the 
summit of the brain, was a third cyst, scarcely an inch long, of about 
half that breadth, and somewhat flattened. Its walls were formed 
by a hard and yellow medullary substance, and it was filled with 
a transparent liquid. One-fourth of the left hemisphere of the brain 
was, you thus see, destroyed ; it was, besides, distorted and drawn 
back, to a degree that I never before witnessed ; even the anterior 
portion of the brain was turned partially round and backward; 
this distortion may have interfered not a little with the exercise of 
the functions of the brain, and was the necessary result of cicatri- 
zation after a complete loss of cerebral substance. 

42 



494 GERHARD'S CLIXICAL LECTURES. 

From this disorganized condition of the brain, which rendered a 
large portion of it as useless as if it had been separated from the 
bod\-, and caused the entire removal by absorption of another part, 
3^ou iPiSy understand the cause of the complete paralysis cf the 
right side of the body, and its necessary incurability, which I pre- 
dicted. But in addition to the immediate consequences of the apo- 
plexy, other changes had taken place in the brain, not necessarily 
the result of hemorrhage ; these were connected with the recent 
active inflammation, from which the patient perished, as was shown 
by the softening around the old cyst. 

A symptom worth noticing was the loss of power of articulation, 
under which, you remember, the man laboured for a long period : 
his answers were confined to the word no, and were atierwards 
brief and confused. Xow there was no lesion, except that caused 
by the contraction, in the anterior part of the brain, which, of 
course, disproves Bouillaud's assertion, that the vocal powers are 
connected with this portion — a point which had, indeed, been pre- 
viously satisfactorily settled by the observations of Andral and 
others. In this instance, the cortical substance of the brain was 
affected, although not in the anterior portion : the cortical sub- 
stance, I have no doubt, presides over the functions of the intelli- 
gence and of the voice. The corpus striatum is supposed to pre- 
side over the faculties of motion of the upper extremity ; and here, 
you see, the patient regained the power of walking, though not 
that of moving his arm. This, however, proves nothing ; for it is 
a regular occurrence in hemiplegia following apoplexy. 

The therapeutics of this case are important ; the impossibility of 
curing it is sufficiently evident, and consequently, the necessity of 
confining your efforts in similar cases to such a plan of treatment 
as will palliate and improve the svmptoms. Hence too, you may 
doubt as to the propriety of addressing stimulating remedies to the 
brain and nervous sj-stem, as nux vomica, or its active principle 
strychnia, to relieve a paralysis dependent on destruction of the 
cerebral structure. These remedies were much in vogue at one of 
our institutions a few years ago, for the treatment of apoplectic 
hemiplegia. I witnessed most of the cases, and I never saw them 
produce decidedly good effects, although pushed so far, in some 
cases, as to produce convulsions. Many patients, afflicted with 
hemiplegia, in a degree recovered ; but this occurred from the 
mere process of absorption of the clot, and not from the effect of 
the remedy. Indeed, I must candidly express my opinion against 
the usefulness of the remedv ; and I am convinced that it often in- 
creases the activity of the circulation in the brain, surrounding the 
clot, from the over-stimulation of this organ. It is a valuable 
remedy in neuralgic paralysis, where there is functional disorder of 
the brain, or mere want of tone in the limb ; but when there is any 
considerable derangement of the cerebral structure, I am quite 
sure that it is often a hurtful medicine, even when given in minute 
doses, and suspended as soon as its effects appear. I make these 



APOPLEXY. 495 

remarks upon the strychnia, because its use seemed indicated in 
one otMhese cases of paralysis; and although I anticipated but 
little effect from it, I consented to its administration ; but it very 
soon became necessary to suspend it, from the increase of the dif- 
ficulty of speech, and rigidity of the limbs. I am aware that many 
physicians of high judgment employ and recommend the strychnia ; 
but my own observations, which were the more unbiassed, as they 
were made upon the practice of others, and not upon my own, 
have led me to a different conclusion. The true therapeutics in 
paralysis from apoplexy, consist first in subduing the inflammatory 
symptoms or the active congestion of the. brain, by blood-letting, 
appropriate applications to the head, and purging ; afterwards in 
waiting patiently and quietly, in keeping from the patient all causes 
of irritation, and in regulating his diet ; and after the clot has been 
removed, in addressing gentle stimulation to the paralysed part; 
or what is better, in directing the patient to move it himself Even 
this slight, and, as it were, natural mode of exciting the bram,may 
be attended with inconvenience. I lately directed a p^ftient, in 
whom the paralysis was already of some month's standing, to 
move his arm every day by a powerful effort of will, and he went 
on until he succeeded in raising his hand to his head, but the brain 
became excited, he was stupid, and his speech thicker, and I was 
compelled to make him desist. Avoid, then, all causes of excite- 
ment, whether medicinal or other, in these cases of paralysis, 
which are either the mere effect of a considerable rupture of the 
fibres of the brain, or are connected with the subsequent inflamniihi 
tion till very late in the treatment, and let it be confined to exter- 
nal stimulation. 

The case which we have just been noticing, illustrates extremely 
well the advantages of a knowledge of pathological anatomy, in 
the study of diagnosis. We were able to define with exactness the 
morbid condition of the brain as you may see from the pre^vious lec- 
ture, which corresponds precisely with that which a post mortem ex- 
amination has laid open. Now this verification, by means of ex- 
amination after death of the lesions in a certain number of diseases, 
enables us to form a much more vivid and distinct picture of the 
state of the analogous cases. We conceive, as it were, in our 
mind, a well-defined picture, and by a sort of second sight, can 
discover most of the changes, which are, under ordinary circum- 
stances, completely concealed. If we gain but little direct assist- 
ance in therapeutics from pathological anatomy, we obtain a sort 
of touchstone, by which we judge of the power of remedies, and 
thus acquire more accurate notions of the effect of n)edicinal agents ; 
we learn to discriminate between the natural course of a disease 
and the modifications impressed upon it by art. In itself, patholo- 
gical anatomy is a mere instrument ; but by its aid we are enabled 
to know positively a multitude of facts, which we can barely con- 
jecture from the unaided study of symptoms. Now, I would im- 
press upon you the necessity of not attaching an exaggerated 



496 GERHABiyS CLDSICAL LE J 777. IS. 

importance to what is a niere means of iii~z : r 
never is>]ate the lesons of an oigan from th^ 
company them. I am the more earnest :: 
matter, becaose yon might imagine, firoffi the :^ ^ _ 
investigations which I endearonr to make, that I vaki 
kiiowlecige for its own sake: this w. j!d "ze iz emr in vvl^ch i 
^looid be loath to fall 

In coDcloding these \ecv::z s ci ib^ brain, I have 

some few remarks to make .r'lanal afiections of 

that organ, occoBrrii^ doriir Jtm disord^s of 

the bod F. These a&ctioas ^ t ^ ---:i often not a 

little pozzling in their character. F 3 donbt sop- 

posed, wh^i listening t? "t : t - • bercnlar 

menii^itis, that the fea: 5 clearly 

marked, and yet there : 
a degree that will emfc 7. 
no easy matter always 

itself, aAd those wr ' '^ . 1 -^ 

this can only be d r^efonctiona. 

changes, that yoo , a- .. were, in yoor 

mind's eye, and c _ t and the true cerebra 

diseases, by a rapid pr s it is sometimes 

termed, by way erf" ex : 7 over the list of 

these anak^onsdisordT 7 7 : n oat of yoor 

calculations, becaose ? : v^antii^- 

^-^rst, in fevers, the lat- 

ler, there occc^- - '^ '''^^- 

amcngst the : 

:' : 7^:? ;: : ; _ :v. 2.72 :i.:i:c£: wi t 

i "'■oo <rf the occas 
: zieral, andare 
i r 1 J ? ff Ter rarely : : 

id: while in ire >reat^ 

^ -^-^h these fever 5 -^^^Te^ 

isd^reethg- ^ 

5 7 . 7iiache a:; :: 

£:. . . r:^i :hefie i« < : : 

typiuca^ «ii 1 - '. - ^ 

Inve, at .^3 

nervoGs sysiem, mdicaied 

those which occor in deliri j 7 

paired in the second sta ^ 7 

severely in typhos than it 

have coma, complete loss c 

tioB, and very nearly com: 

times we have violent, nois 

as an irr^nlar symptom. 

coEDplication of meoiogitis ._ . . z..^ 



FUNCTIONAL DISORDERS OF THE BRAIN. 497 

rium occurs, it is always to be considered and treated as a secondary 
meningitis. Tlie ordinary moderate cerebral symptoms, are, as it 
were, essential to the disease, and do not demand special inter- 
ference, unless they should become intense, when they may be the 
immediate cause of death, and must then be treated as inflamma- 
tions of the brain, by local depletion with cups and leeches, and by 
cold to the head, and the like. If this secondary meningitis of 
fever occur very late in the disease, general bleeding is not often 
advisable. Treatment, although useless in slight cerebral symp- 
toms, becomes essential when they reach a high degree of activity. 
After coma supervenes, it is proper to abandon a depletory course 
and the cold effusions, and you are now to resort to counter-irri- 
tants, sinapisms to the feet, blisters to the nucha, and to the tem- 
ples or over the posterior part of the head — remedies which are 
improper during the violent stage of the secondary meningitis. In 
the partial epidemic of typhus which occurred last winter, the 
fever was attended with more active cerebral symptoms than had 
previously shown themselves. 1 used local treatment, in nearly 
every case, with extreme advantage, and found that, after removing 
the meningitis, the fever was almost free from danger. 

In the intermittent and remittent fevers, the functions of the 
brain undergo alteration, although there is rarely active inflamma- 
tion of the organ. There is less disturbance of tiie powers of mo- 
tion than in typhus and typhoid fevers, subsultus seldom occur- 
ing. The senses are not affected, except in the height of the 
paroxysm, there is little ringing in the ears. These symptoms, 
however, are sometimes present in the malignant intermittents that 
v;e meet with in our hospitals, in the summer, occurring principally 
in sailors who have contracted the affection on the coast of North 
Carolina. In such cases, local depletion is not often advisable, for 
the cerebral symptoms are not confined to the paroxysm, nor do 
they resemble those of acute meningitis; they are rather loss of 
memory, sighing, and other signs of enfeebled nervous energy. 
They are best managed by large doses of quinine during the inter- 
val, and during the paroxysm by wine and volatile alkali. Upon 
these symptoms the danger of malignant intermittents chiefly de- 
pends. Of course this mode of treatment is not designed for those 
cases in which there are signs of moie active vascular excitement, 
requiring the treatment of the acute cerebral symptoms of typhus, 
or to cases in which the face presents a deep red or purple flush, 
as is the case in the apoplectic form of congestive disease. 

In pneumonia, there is usually some slight disturbance of the 
brain, which, indeed, accompanies, in a greater or less degree, all 
febrile affections. Special treatment is required, only when there 
is either active delirium, or much stupor. When these exist, the 
case may be very readily mistaken by one not well accustomed to 
recognise pneumonia. In the cerebral complications of pneumonia, 
the peculiar flush of the face, the dvspnoea, and dilatation of the 

42* * 



498 GERHARD'S CLINICAL LECTURES. 

nostril^', serve to distinguish the nature of the affection, while, if 
there be nneningitis of a primary character, it will be nnarked by 
the brightness or injection of the eyes, frown of the forehead, and 
absence of the purple hue, and dark red flush. In the cerebral 
complication of pneumonia, a special treatment is occasionally de- 
manded, consisting of purging, and antiphlogistics directed to the 
brain. 

In inflammations of the serous membranes of the thorax or ab- 
domen, the brain is rarely implicated, except to a slight extent, cor- 
responding with the vascular excitement. The same may be re- 
marked of inflammation of the mucous membranes; in that of the 
bowels, the functions of the brain are not usually disordered, except 
in the last stage. If, however, the mucous membrane of a large 
extent of the alimentary canal be simultaneously attacked, then the 
brain sympathises, and delirium very commonly ensues. In very 
severe epidemics of malignant dysentery there is also extreme pros- 
tration of the nervous functions, somewhat similar to what occurs in 
intermittent fevers. 

The connection between functional disorder of the brain and 
anemia, was alluded to in the last lecture, and illustrated very 
strikingly, by the history of a case which I then detailed. The 
sympathetic afl^ection of the brain, in jaundice, is well known. We 
have a patient at this time, in the hospital, labouring under chronic 
gastritis and jaundice, in whom this cerebral alteration, depending 
on jaundice, is very manifest, and last year there were several 
marked cases of this kind. It is not, at least at first, of an inflam- 
matory character ; the symptoms being merely stupor and prostra- 
tion, with subsultus, and particularly, loss of the memory. This 
set of symptoms indicates the connexion which exists between this 
affection and malignant intermittent and remittent fevers, and in 
both it depends, in my opinion, upon the altered state of the blood 
which accompanies hepatic disease. Treatment is to be confined 
almost entirely to sinapisms and blisters, and occasionally some 
slight stimulants in addition to the general treatment for jaundice — 
cupping or other depletion should be rarely used. But if the more 
settled and acute symptoms of meningitis supervene, the treatment 
must at once be antiphlogistic. Dr. Marsh, an Irish physician of 
eminence, has also called the attention of the profession to the cere- 
bral symptoms of jaundice, and recognises their great danger. 
Anemia, dependent on a vitiated condition of the liver, is attended 
with many cerebral symptoms, sometimes these belong rather to 
the nervous system and spinal column than to the brain ; in other 
cases there are many signs of disturbed action of the brain itself. 
It is to be treated by tonics, iron, porter, and a generous diet. But 
in many disordered conditions of the cerebral functions, the proper 
remedies are to be found amongst the narcotics and antispasmodics. 
On the same principle is based the practice, recommended by Dr. 
Graves, for the sleeplessness and slight delirium in the latter stages 
of typhous fever, consisting in a combination of opium and tartar 



DELIRIUM TREMENS. 499 

emetic. This is an excellent rennecly ; the antimonial slightly nau- 
seates, promotes gentle perspiration, and predisposes to sleep. The 
virtues of Dover's powder depend on the combination, of opium 
with an analogous medicine, ipecacuanha, and, if the alimentary 
canal be in an irritated condition, this combination is to be pre- 
ferred. 

I have entered thus minutely into the detail of these functional 
cerebral symptoms, and into the points which distinguish them 
in different affections, because the symptoms, which are laid 
down in books, are more or less analogous in all these affections. 
The order of symptoms, however, is very different, and diagnosis 
becomes comparatively easy if we attend to their successive deve- 
lopment. 



LECTURE IX. 

Delirium Tremens. — Symptoms. — Stages. — Varieties. — Complications. — Treatment 

Delirium tremens is an affection which has special claims upon 
your attention, from the lamentable frequency of its occurrence in 
our country. It is here, amongst the labouring classes, particularly 
the Irish, ^ one of the most common of diseases, although in France 
and other continental countries of Europe, comparatively rare. 
During my residence in Paris I did not see a single case of it : in 
the hospitals of that city it is a disease that is never thought of, in 
patients who enter with cerebral symptoms, although with us cases 
of delirium tremens are more numerous in our hospitals than those 
of all other cerebral diseases together. 

I now present a case of simple delirium tremens. The patient 
has been a drunkard from his twelfth year, and he is now upwards 
of forty ; the fit of intoxication which gave rise to his present disor- 
der commenced before Christmas, and continued until his entrance 
into the hospital a few days since. On looking at this man, the first 
thing that strikes your attention is a universal restlessness ; the whole 
body is affected with tremors; when he holds out his hand, he is 
unable to keep it still ; his tongue when protruded, is similarly agi- 
tated, but not to the same degree. Besides these tremors, last night, 
and several preceding nights, the patient Xvas affected with halluci- 
nations of mind ; these are still present, but are much less manifest 
than they have been. As I have stated in a previous lecture, fear- 
is an almost constant characteristic of these hallucinations of de- 
lirium tremens ; but the fear is less of present, than of absent and 

♦ The very happy reformation which has taken place among the Catholic Irish 
requires this statement to be modified. 



500 GERHARD'S CLIXICAL LECTURES. 

imaginary objects. From this fact we derive an important lesson 
in the treatment of this disorder; that is. never to excite the fears 
of the patient, but to reheve them as far as possible by permitting 
him to have free intercourse with others : this will divert his mind 
from those terrifying objects which his imagination brings before 
him. The patient is always conscious of these hallucinations until 
h's ]7/z][zi:,ce is entirely destroyed. They are most frequent and 
c:5:; e-- .g .vhen he is shut up in a cell ; in company they are much 
less so, and more under the control of his mind. 

In consideration of this subjeci, the important question occurs to 
us, what is mania a potu, or delirium tremens? It is not inflammation 
of the brain or its membranes: for the symptoms of these diseases 
are constant; there is a permanentdisorder of intellect, and a lesion 
of muscular power throughout many parts of the body. In delirium 
tremens, on the contrary, there is no such constant and decided 
muscular disorder; there is no rigidity or paralysis, but only agita- 
tion and inability to keep still. Nor is there any positive defect of 
vision, or of the other senses, other than illusions or hallucinations ; 
they are still perfectly retained, andentireh' under the control of the 
patient. The condition of the intellect is likewise different ; in in- 
flammation of the brain there are rarely hallucinations, properly 
speaking, but a more or less complete destruction of consciousness 
and aberration of intellectual power : in both these respects, we 
observe an opposite condition in delirium tremens. This marked 
difference in the sj^mptoms is explained b}* a reference to the patho- 
logy of the two diseases. In inflammation, there is injection of the 
membranes or substance of the brain, with thickening of the former, 
and various other organic lesions. In delirium tremens there is no 
organic change; the only abnormal appearance which can be de- 
tected, is an effusion of seruMi into the ventricles of the brain, and 
a preternatural moisture of the cerebral substance. This super- 
abundance of fluid arises from the continued irritation to which the 
brain is subject, and the slowness with which it occurs ; it is not the 
cause of the symptoms ; they are produced by the irritation, which, 
after it has continued for a longer or shorter period, gives rise to 
the effusion. The two diseases also differ in their progress. Mania 
a potu, like measles, scarlatina, &c., has a definite course and a 
natural termination ; it must disappear after a certain time, unless 
the attack be a very severe one. Xo treatment is of any further 
use in the mild cases than to diminish the inconveniences of the 
disorder; any treatment which is not dii-ected to this simple end, 
proves injurious by irritating and harassing the patient. 

DeUrium tremens begins in two different ways. The most 
common is that in which from some cause, as accident, disease, or 
resolution of the patient, or inability to obtain intoxicating drinks, the 
patient suddenly gives up his accustomed stimulus. This is the 
most simple variety, nnd under ordinary circumstances, after a period 
of restlessness of two to three days, passes through a natural crisis, 
consisting in a prolonged sleep of some hours, and terminates in 



DELIRIUM TREMENS. 501 

recovery. If no untoward circumstances occur, the sleep will 
follow of itself, and the disease is therefore strictly a self-limited 
one; treatment merely assuaging the suffering of the patient and 
diminishing the mortality. The second mode of invasion is that in 
which the delirium tremens is most apt to be complicated with in- 
flammation or congestion of the brain or stomach, or with convul- 
sions. The patient continues to drink freely until his attack, but the 
stimulant is taken irregularly, or acts irregularly, strongly exciting 
the brain at one moment, and then leaving the patient in a state of 
depression. The circulation is often much excited, and the face 
flushed, and the eyes injected. These cases are apt to be attended 
with convulsions of a mixed form-, sometimes resulting in apoplexy, 
at others epilepsy. These convulsions sometimes, though rarely, 
occur immediately on a debauch, more frequently, however, they 
take place in patients who are in a state of vascular as well as 
nervous excitement from intemperance, and suddenly abandon all 
stimulants. The convulsions, and indeed this variety of the disease, 
are not so frequent in the poor as in those who, with more means of 
gratifying their vicious desires, are sunk into greater debauchery. 
The hallucinations and other disturbances of the intelligence are less 
marked in this variety than in the ordinary form. We may state 
this by saying, that the vascular and nervous symptoms are more 
developed, but the intellectual less so. 

For the study of ordinary delirium tremens, it is convenient to 
divide the disease into three stages : — 

(a) First Stage. This is well known amongst drunkards as the 
horrors : a term which expresses the aspect of the patient, which 
is that of extreme anxiety and agitation, and the distressing feel- 
ings of fear which the patient experiences. This anxious alarming 
expression is one of the most characteristic symptoms of the disease, 
and with the tremor, which is equally remarkable, it constitutes the 
only pathognomonic character. The tremor extends to the whole 
muscular system, but as it may be to a certain extent restrained by 
a voluntary effort of the will, or by supporting the weaker muscles 
of the limbs against the trunk, it is sometimes not very obvious 
unless the patient is directed to put out his tongue, or to hold up 
his hands, where it is at once perceived. The restlessness and 
tremor are the most frequent and important symptoms of the first 
stage of the disorder, but are by no means the only ones ; the others, 
however, are only accessory or secondary, and vary with each pa- 
tient. As a general rule, the pulse is feeble and frequent, the mind 
is unable to direct itself long to any single subject, and the pupils 
are slightly contracted. The complexion is extremely variable; it 
isoften pale if the patient has not been long addicted to intemperance, 
but, in the majority of cases, it retains the usual tint of the drunkard's 
countenance. The appetite fails, the bowels are often constipated, 
and there is generally more or less thirst. In this stage of the com- 
plaint the restlessness continues throughout the night, and of course 
the patient is unable to sleep : sometimes, the sleeplessness is the 



502 GERHARD'S CLINICAL LECTURES. 

first symptom of the disease, but in the majority of cases it attends 
the restlessness, and is strictly proportioned to it. The agitation 
may gradually subside and the patient recover, or the disease may 
pass into the next stage. 

(b) The second stage of the complaint presents the same symp- 
toms as the first, but in an exaggerated degree, the tremors, rest- 
lessness, and insomnia are increased, and the appetite is more com- 
pletely destroyed. The pupils are more contracted ; if, however, 
the patient has not taken opium, the contraction of the pupils is 
never very great. The distinctive symptom of the second stage, 
is the illusions which at first occur only at night, when the patient 
is left alone, and in the dark. These hallucinations are perfectly 
under the control of the understanding when the courage of the 
patient is revived by light and society : he is then perfectly avtare 
of their nature, and will often laugh at his own fancies. The illu- 
sions are not confined to the nicrht, if this staoi;e become more con- 
firmed, but they still remain perfectly under the control of the will 
and of the intelligence ; if the disease continue, the illusions become 
more and more frequent, and cease to be recognised by the patient, 
that is, they are completely confounded with real objects. The 
attention may still be directed to surrounding objects, and the pa- 
tient is capable of answering ordinary questions with perfect cor- 
rectness, if he is addressed in a sharp, decided tone of voice, and 
there is no incoherence in his answ^ers, so long as his attention can 
be commanded. These illusions are nearly always of an alarming 
kind, and are as varied in their nature as the objects which happen 
to be most familiar to the patients ; devils, guns, fire, serpents, and 
the like, are the most common objects of his fear. At other tin)es 
he feels a vague dread that his life will be taken, and earnestly 
entreats that it may be spared. These illusions are so well cha- 
racterised, that the}^ have always been regarded as the essential 
character of true delirium tremens ; this is nearly but not abso- 
lutely correct, for, in some cases, the tremors are not attended with 
illusions, but on the contrary, the mind of the patient is almost 
clear, and the disease may prove fatal, although no illusions present 
themselves, by the occurrence of convulsions or sudden insensibilit\\ 
Still, in the regular simple variety, of which I am now treating, the 
illusions may be regarded as a constant symptom. The other 
symptoms of the second stage are not pathognomonic, and with the 
exception of the countenance, wdiich retains the same restless ex- 
pression as in the first stage, are not even characteristic. The pulse 
is frequent, and generally small, the frequency evidently depends 
rather upon the extreme agitation of the patient than any regular 
connection between the state of the circulation and the disease. 
The appetite rarely returns during this stage, although this is 
sometimes the case ; the tongue is generally furred, but rarely dry. 
The skin remains moist throughout this stage, and if the efforts of 
the patient to escape from confinement be constant, or if his agita- 



DELIRIUM TREMENS. 503 

lion be very great, the sweat is often very profuse. This sweat is 
of a different character from that which generally occurs during 
the third stage of the disorder, and seems to be strictly dependent 
upon the constant exercise which the agitation of the patient obliges 
him to lake. The second stage may gradually decline, and the 
patient fall asleep, and recover; or it may pass into the next stage. 
Sleep is nothing but the indication of the recovery ; it follows rather 
than precedes the decline of symptoms. The insomnia arises from 
the extreme nervous disturbance which is the essential element of 
the disease, and although the fatigue of the patient may be extreme, 
he is still altogether unable to sleep. Let the nervous agitation be 
quieted by any means, and sleep vi'ill immediately follow, and will 
finally complete the restoration. This is the true rationale of the 
close connection between sleep and recovery, which has certainly 
been misunderstood, and has led to erroneous deductions as to the 
treatment of the disease. If the disease be completely removed, the 
patient will sleep for a long time, and will generally awake perfectly 
restored. In some cases, however, the recovery after prolonged 
sleep is not complete, but the disease recurs again, and is not 
completely cured until a day or two afterwards. If the prolonged 
sleep occur naturally, it is always productive of great relief to the 
patient, but if it be forced by the operation of narcotics in large 
doses, instead of conducing to recovery, it will sometimes end 
fatally, and the patient may then die without awaking. A short 
sleep of one, two, or three hours is refreshing, but is not usually 
followed by immediate recovery, although it affords an evidence of 
the gradual decline of the disease. If delirium tremens be well 
treated, or if the disease be essentially mild, but. few cases pass 
beyond the second stage ; recovery taking place without difficulty, 
(c) The third stage is attended like the others, with a symptom 
which is characteristic ; that is, incoherence. The illusions either 
cease, or they are no longer connected, — the patient passing from one 
object to the other with great rapidity, and not reasoning corectly 
or connectedly upon the images which are presented to his mind. 
He becomes feeble, but is, at the same time, extremely agitated, 
and can only be retained in bed by the constant watchfulness of an 
attendant, or by straps or bandages. The sweat becomes profuse, 
the skin sometimes cold, at others warm, and pupils greatly con- 
tracted. The contraction sometimes ceases before death, and 
may be succeeded by a morbid dilatation, if there be much serous 
effusion upon the brain. The senses become gradually more and 
more obtuse, from the first appearance of incoherence ; the patient 
generally loses his power of attention, and can with great difficulty 
be induced to direct his attention to surrounding objects, and as 
the disease advances, he becomes completely comatose, and gene- 
rally lies in a state of insensibility for some time before death. 
The pulse gradually fails during this period, and the patient often 
presents symptoms of nervous disturbance, which are very ana- 
logous to those which take place in cases of typhus fever, such as 



504 GZLHAluD'? CLDQCAL LECITL^JS. 

iE^ (ifeliriQin. 

lave ftcqineil^ isea en^io^ £ir Ifae ciive of ihs 

Hbe^ ad % prodnc^ iciasiiliora 

verywdL Bmii 
(ffifcriiiyMMiKtf sprtwlMdhBMottiM^^ 
prac^Boe^ wbeae die dnomder is bnM^ OB. Bot ii^ 
iKi^ bitt bf at feii^cnarae office dbrafti^^ 
deal of ham ; Mhad of ti»|yai^ mIk: ^ste»^ 

a, gseai deal of 

_1 ^ I_ Tartar ©z 

licis _ 

liam Unaia e ii, opines have pEolnfalj 

aslai^dos^asameof njIweflHai; baft wheal 

lai^ dosei^ — fic i yg— ly as HiBcii as famr graias esay two 

,_ : _^ _ , Tic palkHi^ for ifae c 

part.gaA 




DELIRIUM TREMENS. 505 

Instead of confining the patients, I let them walk about and enjoy 
the company of others as much as they choose : merely taking care 
that some one should be near them to prevent accidents. 1 was 
led to this change by observing that the hallucinations which attend 
the disorder were more distressing when the patients were in a 
state of confinement than when they were allowed to walk about 
as much as they wished. As I have already remarked, they are 
capable of controlling these hallucinations, until the intellect is en- 
tirely destroyed ; and they can do so the more easily when they 
are surrounded by objects which serve to engage their atten- 
tion. Confinement always irritates them, and increases their 
ravings, so that the third stage, in which the intellect is entirely de- 
stroyed, is apt to be brought on very speedily. I have very often 
tested this by a simple experiment; a man who was confined to his 
bed by a straight-jacket or something of the kind, I have frequently 
directed to be dressed, have soothed him by conversation, and after 
requiring a promise that he would conduct himself with propriety, 
I have very seldom found reason to be dissatisfied with the result. 
On the contrary, the disease would almost invariably become 
milder, and the necessity of confinement cease. It is true that 
confinement is often necessary at night, from the impossibility of 
alwa\s providing a sufficient number of attendants. I therefore 
(with the exception just stated) allow the patient to have full liberty, 
the only restraint being the presence of the keeper : sometimes, also, 
I direct them to be set at work, which serves still farther to dis- 
tract their attention. 

The proportional mortality under the two plans of treatment 
which 1 have detailed, is represented in the following summary, 
comprising ihe number of cases treated amongst the men for the 
space of 5^ years — that is, from the 20th of May, 1834, to the 13th 
of November, 1839. The whole number of cases admitted for de- 
lirium tremens, or intemperance, which was expected to terminate 
in delirium tremens, was 1241. Of these, there were 1198 whites, 
and only 43 men of colour. Of the whole number, 708 were de- 
cided cases of delirium tremens, 60 were slight cases, and 430 cases 
of mere intemperance. Of the latter, some terminated in decided 
delirium tremens, and others proved fatal from diseases (such as 
pneumonia) contracted during the fit of drunkenness, for which they 
had been sent to the lunatic asylum. So that this class furnishes a 
considerable number of bad cases. Of the whole number 121 cases 
proved fatal. That is, a fraction less than one in ten. 

In the first year, from May, 1834, to the same date, 1835, the num- 
ber of admissions was 141; of these, 18 died; that is, rather more than 
one in eight. In the second year the number of cases was 211, the 
deaths 24, or a little more than one in nine. The third year, in 
301 cases, there were 47 deaths, a much larger proportion than in 
preceding years, one in 6 19-47ths, but depending upon an accidental 
cause, that is, the coincidence of an epidemic of typhus, which at- 
tacked many of the debauched subjects of intemperance : some of 

43 



506 GERHARD'S CLINICAL LECTURES. 

them were sent to the lunatic asylum as labouring nnerely under 
the effects of intemperance, and could not be afterwards removed 
to the proper ward. 

In the fourth year, beginning May, 1837, of 206 cases, 19 only 
proved fatal, that is, about one in eleven. This was a decided 
amelioration, and coincides precisely with the epoch at which the 
change of practice was introduced. 

In the fifth year the mortality w^ent on diminishing, and was less 
than one in twenty-six ; or of 274 cases, 9 only were fatal ; and 
amongst these cases, the mortality was certainly greatest in those 
which were treated chiefly according to the method formerly pur- 
sued at the hospital. 

Finally, in the six months, ending November, 1839, the mortality 
was only one in 33|, that is, 4 cases out of 135 ; and of these four, one 
entered moribund, and was not, therefore, treated in the hospital ; 
another had inflicted upon himself several fractures and other inju- 
ries, by leaping from a third story window, in a fit of delirium tre- 
mens, previously to his entrance. The others, it is believed, were 
also comphcated cases. 

The preceding summary of the results of the treatment, is 
extracted from a lecture which I deUvered at the Philadelphia 
Hospital, in December, 1839. The results of the treatment for 
the last year, up to October, 1840, have been still more satis- 
factory. The number of cases of the sequelse of intoxication, and 
of delirium tremens in the three stages, admitted into the men's 
wards of the Philadelphia Hospital, from October 12. 1839, to Octo- 
ber 12, 1840, is 223. Of these, 61 were classed under the head of 
intoxication or its immediate sequels, some of them passing into 
delirium tremens. If we exclude the whole of these 61 cases, there 
remain 16*-^ cases of decided delirium tremens; of these, 87 w'ere 
admitted in the first stage, 73 in the second, and 2 in the third : 160 
cases recovered, and one remained convalescent, who is since well. 
(Oct. 16.) One only proved fatal : this patient was admitted in the 
third stage of the disease, and died in a few hours after his entrance ; 
he had been treated with opium, and a box of pills which he w^as 
taking, were sent to the hospital with him. Of course, this apparent 
exception confirms the general conclusion, that the disease termi- 
nates favourably in every instance, when treated according to the 
method recommended. 

Up to the present date, August, 1841, from November, 1840, the 
mortality, including complicated and moribund cases, has been 
about one per cent. That is, in no case in which the stimulant 
practice was thought necessary did it fail, except in those in which, 
from the late admission of the patient, or some other accidental 
cause, it was not fairly tried ; and counting all such, the ratio still 
remains insignificant : while the opiate practice yielded a large nrior- 
tality under the same circumstances. I do not, however, think it 
necessary to resort to alcoholic stimulants in slight cases; and 
still less in the slight gastric nervous disorder which follows sim- 



DELIRIUM TREMENS. 507 

pie intemperance, but does not amount to delirium tremens ; some- 
times it is better to avoid them carefully under these circumstances. 

The plan of treatment which I have found to answer best, is as 
follows : — 

If a patient come under your care partially intoxicated, but still 
labouring under some of the premonitory signs of delirium tremens, 
give him an emetic of ipecacuanha : he will in general be disposed 
to sleep after its operation ; when he awakes, or soon after taking 
the medicine, if he does not sleep, he will complain of gastric 
uneasiness, and often of slight nervous symptoms. Fresh air, 
exercise, and a strong infusion of gentian, or some other bitter, 
with capsicum or ginger, will then do much to allay the irrita- 
bility of the stomach and diminish his discomfort. Alcoholic sti- 
mulants are not necessary in such cases ; and these simple remedies 
constitute my usual treatment. 

If the disease promise to become more protracted, a mixture of 
lac assafcetidse, with tincture of valerian (ammoniated), and Hoff- 
man's anodyne, (5ss. of each of the latter remedies with jiij. of 
lac assafoetida every two hours,) are of great benefit in tranquil- 
lizing the patient. As a drink, he may take a bitter infusion with an 
aromatic. These remedies with exercise, and as nutritious a diet as 
the stomach of the patient will bear, are sufficient. 

If the disease become more decided, and pass to hallucinations, 
especially if these are not recognised as such by the patient, the 
stimulant practice maybe resorted to. The severity of the disease 
from the first is, however, a better guide than the mere occurrence 
of hallucinations. Thus, if the disease be very violent, even before 
any hallucination can be detected, the patient may take alcoholic 
stimulants; but it is especially in those cases in which both tremors 
and hallucinations are present that the stimulant practice is appli- 
cable. The same treatment is indicated when the patient is threat- 
ened with convulsions; but if the face be flushed and more or less 
livid, the cold affusion, or the simple application of ice to the head, 
should be conjoined with the stimulants. 

Various alcoholic preparations will answer the same end. Whis- 
key with quassia is by no means palatable, and at the same time 
suits well with many drunkards, but some of them are nauseated by 
it, and require brandy, gin, or the like. The dose is necessarily very 
various : on no account, and under no circumstances, is it either ne- 
cessary or proper to give a sufficient quantity to render intoxica- 
tion possible. Our object is the very reverse of this : it is simply 
to tranquillize the agitation of the nerves by small doses of a 
poison to which the patient has been accustomed, but not tox- 
icological doses ; and these small doses may seem large in some 
patients, although they are in reality small compared with their 
habitual allowance. For most purposes, one ounce of the above- 
mentioned stimulants may be given every three or four hours; in 
bad cases, two ounces may be given every two hours, for a few 
doses, and then in a less dose. In very few cases was this quantity 
exceeded, and then only for a very short period, when the life of 



508 GERHARD'S CLINICAL LECTURES. 

the patient appeared dependent upon the prompt revival of his 
sinking powers. If the patient be feeble the stimulant may be 
gven in the form of milk-punch, or in arrow-root. The largest 
dose is generally required for a single day, afterwards it should be 
gradually lessened, and after a sound sleep, or as soon as there is a 
decided diminution of the tremors, all alcoholic remedies may be 
given up and supplied by a simple bitter infusion, or the assa- 
foetida mixture. In some cases the cure takes place, as it were, 
abruptly, and the patient is' at once restored to health ; in others, 
after the cessation of violent symptoms, the patient may remain in 
a nervous state with some tremors, but no decided hallucinations: 
there is at the same time in many cases some indications of active 
excitement of the brain. This state of things is, however, much less 
frequent after the alcoholic than the opiate practice; but in either 
case, the best remedies are a smart purgative, exercise in the fresh 
air, and cold affusions on the head. 

There are often complications which require some modifications of 
the treatment, but they are less frequent than in the opiate practice. 
The most common is gastritis ; to a greater or less extent it may 
be said to be natural with drunkards, and ceases in a great degree 
as soon as the cause is removed ; if it be not very intense, it requires 
no special treatment. This slight gastritis is often attended with 
vomiting, which ceases after an emetic, or the administration of the 
usual stimulants. If, however, the disease be severe, with red tongue, 
and great tenderness, and constant vomiting, all stimulants should for 
a time be suspended, or they may be given in small quantifies and 
iced. Bladders, or cloths, containing ice, may be applied to the epi- 
gastrium, the proper diet for gastritis directed, and cups and leeches 
may be used if the former remedies prove insufficient. When the 
gastritis becomes very intense the s3'mptoms of delirium tremens 
in general subside, and seem displaced by it ; and the brain symp- 
toms become then secondary to gastritis, such as fixed but mutter- 
ing delirium. These are often confounded with those proper to 
delirium tremens. Congestion or inflammation of the brain may 
complicate, replace, or succeed to delirium tremens: when they 
appear as mere complications they may often be relieved by the 
means I have indicated without suspending the treatment proper to 
the disease. But if the vascular disturbance of the brain constitutes 
the disease, and the delirium tremens is either not developed or dis- 
appears, the treatment becomes that which is adapted to the parti- 
cular cerebral state, and venesection is sometimes under these cir- 
cumstances of immense value ; but, as a general rule, local bleeding, 
revulsives, and refrigerant applications, are better means of restor- 
ing the balance of the system. These vascular affections of the 
brain are always produced in some individuals after a debauch, or 
even moderate indulgence ; in a few they may occur upon taking a 
single glass of wine. Of course, in the latter case they are depend- 
ent upon a peculiar idiosyncrasy, in which a very small dose of an 
alcoholic stimulant acts as a virulent poison. If the vascular ex- 



DELIRIUM TREMENS. 509 

citement of the brain from a debauch be not attended with the 
symptoms of real delirium tremens, or if they be very slight, and be 
concealed as it were beneath those of excitement, then it is very 
clear that the case should not be treated as one of delirium tremens ; 
— an error of diagnosis in this respect would he mischievous. 

In pointing out to you a mode of treatment which a long expe- 
rience has shown to be safe and remarkably certain in its results, 
I am very far from excluding other means as injurious; on the con- 
trary, many of them may be used in connection with the stimulant 
practice, or maybe substituted for it, if you have strong objections 
to this mode of treatment. Should you prefer opium, I would warn 
you against giving it in very large doses, except you can observe 
the condition of your patient before administering each of them. 
By combining opium with tartar emetic or ipecacuanha, you may 
succeed in producing calm or sleep in smaller doses than if given 
alone. Although it was the retnedy formerly relied upon in the 
hospital, I have not administered it for two years, except in rare 
cases for some intercurrent disease, such as dysentery. In some 
instances, as of fractures of limbs, &c., it may be necessary to 
use opium, but these are rare: there is another case in which it 
may be of service, that is, when the patient is tranquil, but still 
sleeps little; a moderate dose of opium is then at times of service. 

In recommending to you a practice of this kind, I do so simply 
because I believe it to be a duty to inform you of the results of my 
experience in the treatment of this disorder. The great success of 
the treatment is a matter of demonstration ; while there can be no 
possible objection to the practice, except the fear of giving some- 
thing like a sanction to the assertions occasionally made by drunk- 
ards, that they cannot do without their stimulants. This, however, 
is clearly an error: the continued use of alcoholic liquors even as a 
remedy is always injurious and reprehensible; but this is very dif- 
ferent from their employment during the two or three days of an 
attack of delirium tremens. 

The examination of the records of the hospital do not show that 
the admissions for delirium tremens of the same individuals are at 
all influenced by the treatment in previous attacks, whatever that 
may have been; on the contrary, there is strong reason for believ- 
ing that such is not the case. The thirst for alcoholic drinks, once 
acquired, can only be overcome by a moral action and a strong 
will on the part of the patient ; hence, it is extremely rare to find a 
drunkard reformed from fear of illness or suffering. The will to 
abstain, for it requires an act of strong volition, must come from 
other reasons; and the influence of the societies which are now 
labouring in the reformation of the intemperate, is certainly en- 
hanced by the support which they receive from mutual encourage- 
ment giving strength to the feeble will of the intemperate. 

After a treatment, or after an attack without treatment, of deli- 
rium tremens, the patient should break up his old habits of asso- 
ciation of time and place, take a journey, engage in some oew and 

43* 



510 GERHABD'S CLDQCAL LECTTEES. 

actire employment. Shower baths, or simple cold baths, with some 
light purgatives, are useful in dissipating the remaios of the disease,* 
and ID favouring sleep wheo the disease is no longer in its most 
active stage, but is not entirely removed. 



LECTURE X. 

Djsenterj. — Y3zieti6s>, — Diaaaosis. — Aaatasiical lesions. — Treatment. 

Dtsjls-tery is a disease of uafrequent occurrence in the cold 
seasons of the year. It is most commonly met with in summer and 
fall, llie liability of ini3ammatioQ being transferred with the approach 
to wiDter, from the bowels to the lungs. I, however, present two 
cases of dysentery, one of the acute, the other of the sub-acute form. 

The latter is that of a man aged sixty-five years : he has 
generally enjoyed good health : on his first admission into the hos- 
piial, he bad intermittent fever, from which he recovered, and went 
aboot his usual employment. About a fortnight after this, (on the 
1st of October,', he was a^in admitted, havics^ been seized with 
dysentery two days before. It came on with frequent discharges 
from the bowels, which were watery, and passed with little pain. 
In a few days the character of the stools changed: they became 
yellowish, and were composed of thin f^cal matter, mixed with 
mucus : but there was no blood. The patient has also suffered 
pains, but of no great severity, along the course of the colon, from 
the CGBCum to the sigmoid flexure. He has not experienced naosea ; 
his appetite has been tolerable ; he has sullered little from thirst. 
The skin has been harsh and dry, with considerable emaciation, 
and a countenance indicative of griping pain in the bowels; the 
features which giYe to it this expression, are the frown on the brow 
and compression of the lips. The degree of emaciation has varied 
frequently with the intensity of the case : being on one day extreme, 
— the next much diminished. The pulse has been sometimes quick, 
sometiines slow ; it now beats 96 in the minate. The skin is cool ; 
there is, therefore, ver\- little fever, nor has there been much at any 
time in the course of the disease. The tongue has been, throughout, 
dry, cracked, and red, as it almost always is in severe cases of 
cknudc dysentery. This appearance of the tongue is not so fre- 
qaeQt in acute dysentery, because the inflammation requires sooie 
time lo extend itself up the alimentary canal. In chronic cases we 
obsa find this condition of the tongue attended with a disagreeable 
taste, and eien ulcers in the mouth. The patient's tongue is now 
become natnnil ; abdomen sli^tly tender, and not retracted. 

The acute case is that of a woman, forty years of age. She was 
admitted oo the 12th of ^November. During the summer, she had 



i 



DYSENTERY. 511 

an attack of dysentery, and has since been confined in the wards 
with rheumatism, but had recovered. Her present ilhiess com- 
menced on the 10th inst. The discharges were frequent and 
watery; on the 12lh they contained mucus with some blood. She 
has had fever, but no chilis; nausea, but no vomiting. 

15th. The countenance is anxious; abdomen extremely tender 
and painful; stools passed every hour; they contain mucus, but no 
blood. 

To-day (16th) the blood has reappeared in the stools. This disap- 
pearance and reappearance of blood in the stools are of frequent 
occurrence in acute dysentery. The history of the case shows that 
the stomach has remained nearly intact, the disease being confined 
to the large intestine. 

Present condition of the 'patient. — The countenance is very 
slightly flushed, especially the lips ; there is no compression of the 
lips, as in the former case; the countenance expresses nausea and 
disgust, rather than griping pain. The' skin is moist and pleasant, 
but has been warm and more dry. The tongue is covered with a 
brownish fur, but moist; there is some pain on pressure all over the 
abdomen, but it is especially severe in the transverse colon and 
sigmoid flexure ; pulse moderately strong, but compressible, and 
beats 110. The intellect is confused and weak, but this condition 
is habitual to this woman, and is not connected with the disease. 

I now present a case of tubercular diarrhea ; a disease 
having a close analogy to dysentery. The disease has con- 
tiued for two months, the patient having for some time previous 
been labouring under phthisis pulmonalis. Since the commence- 
ment of the diarrhoea the pain in the chest has continued, but the 
cough has declined, as almost always occurs in such cases. The 
diarrhoea seems to act uniformly as a revulsive, and stills the cough, 
or sometimes removes it for a time. The patient passes five or 
six stools daily; they consist of ordinary fecal matter, mixed with 
serum, but no mucus or blood. 

The diagnosis of dysentery is, in general, easy in acute cases. 
The tormina and tenesmus, and peculiar stools are sufficient to 
distinsjuish it. But in the chronic form of the disease the diaojnosis 

CD O 

is more difficult, as it is apt to be confounded with that form of 
diarrhoea which is produced by a tubercular condition of the folli- 
cles of the small and large intestine, and is usually preceded by 
a similar condition of the lungs. We are to distinguish them by the 
history of the case. Tubercular diarrhoea is, in most cases, preceded 
by phthisis pulmonalis, that is, the disease generally begins in the lungs 
before it attacks the bowels. The discharges are generally irre- 
gular as to amount and frequency, and they differ in nature also 
from those of dysentery, as is proved by ret^erence to the above 
cases. 

Anatomical lesions. — Dysentery is an inflammation of the large 
intestine, as is sufficiently indicated by the position of the pain. 
This inflammation and its consequences in some cases extend a 
short distance into the small intestine, and even to the stomach ; 



512 GERHARD'S CLINICAL LECTURES. 

but it always commences in the large intestine, and is generally 
confined to it. It mostly begins towards the lower end of the colon, 
and is sometimes restricted altogether to within a short distance 
from the anus. The inflammation produces ulceration in various 
degrees ; thickening of the mucous, and other coats ; contraction of 
the cahbre of the intestine, from the spasm of the muscular fibres, 
or sloughing of the mucous membrane, which may thus be exten- 
sively detached. The mucous follicles suflTer much from the dis- 
ease, and the ulceration generally begins in them, and then assumes 
a regularly rounded form ; then smaller ulcers run together, and 
finally give rise to the extensive destruction of the mucous coat 
"which occurs in most bad cases of dysentery. The anatomical 
lesions of this disease are of importance for the prognosis ; for when 
you have become familiar with them you may readily understand 
how slow the intestine is to recover its normal condition; indeed, 
it is apt te remain for a long time more or less diseased, notwith- 
standing the diminution of the symptoms. The contraction of the 
gut is one of the greatest obstacles to perfect cure when the ulce- 
ration has been extensive, for it can no longer bear the distention 
caused by the passage of fecal matter, and every new process of 
defecation is a new irritant to the denuded surface. It is, however, 
surprising to find that the intestine will sometimes, though rarely, 
regain a healthy state after the most extensive sloughing and ulce- 
ration. That is, it will regain very nearly a normal condition, but, 
perhaps, remain a little more irritable than usual. These remarks 
are applicable to the protracted cases of the disease, where the 
ulceration is deeply seated, and the powers of restoration have 
declined. When the disease is acute, the most extended ulcers 
will cicatrize kindly, and leave behind a smooth cicatrix, with 
puckered edges. These I have often seen months and years after 
an attack of acute dysentery, in patients who have died of diseases 
in no way connected with it. The depth of the ulcers is, therefore, 
more important than their extent. 

But the inflammation of the colon is not all; there is something 
more; and you will rarely find that patients can be said to labour 
under a local disease if the dysentery be severe. But although in 
the simple state it is certainly little else than a mere colitis, the com- 
plications render it dangerous, chiefly because the blood and the 
cerebral system are involved. Still, the inflammation of the colon 
is, in all cases, the fixed anatomical character of the disease. 

Treatment of dysentery. — In the acute form of the disease, the 
treatment is sufliciently simple. The usual antiphlogistic means 
are required, with local applications to the inflamed mucous mem- 
brane, calculated to allay its irritability and remove its morbid 
secretions: these local remedies are narcotics and laxatives. In 
the practice of this hospital, especially during the present year, we 
rarely find it necessary to bleed. We give first a dose of castor 
oil, and then make use of the oily mixture. Calomel, either alone, 
or combined with opium or ipecacuanha, is by far the best remedy 
in severe cases; we sometimes also use ipecacuanha alone, or 



DYSENTERY. 513 

Dover's powder. In most cases mercurials are sufficient to effect 
a cure as soon as they produce ptyalism, or just before, when the 
symptoms of acute dysentery often cease at once. Half, or a quar- 
ter of a grain of calomel, every two hours, will salivate in three or 
four days. It is usually combined with opium, to allay the griping, 
and prevent purging; or the pulv. ipecac, et opii may be employed 
in place of the opium, to effect the same objects. I also frequently 
use ipecacuanha, either alone, or combined with opium or calomel. 
In the case of subacute dysentery before us, I have employed 
these remedies, at times resorting to the acetate of lead, and various 
astringents, without much advantage: Dover's powder has pro- 
duced the most benefit. In the acute case you saw to-day, I gave 
half a grain of calomel, with three grains of Dover's powder, every 
two hours. 

I rarely employ calomel as a purgative in this disease. I use it 
for a few days only, to produce its specific antiphlogistic effect, 
— that is, until slight ptyalism is induced. If it is not then attended 
with good effects, it should be given up : a continuance of its use 
will do much injury, and tend to increase the ulceration of the bowels.. 

This is a peculiarity in the action of mercurials ; in many acute 
inflammatory diseases, the advantages to be gained are when the 
point of very slight ptyalism is readied, which is a test of the opera- 
tion of the remedy, and the system may then be regarded as satu- 
rated. I am quite convinced that if, from any peculiarity of the 
system, or from the disease assuming an unusual tendency to the 
spreading of tlie ulcerations, mercury should be administered after 
ptyalism has been produced without benefit, the patient is decidedly 
injured. The remedy is best adapted to the inflammatory forms of 
the disorder, and, as we shall presently see, is least fitted for the 
sloughing or malignant variety. 

Of the particular remedies in dysentery, purgatives have been 
extensively employed. We use many articles of this class in the 
hospital ; the best is admitted to be ccstor oil, which purges 
sufficiently to carry off' ihe vitiated secretions, without pro- 
ducing much irritation. To prevent the oil from acting too harshly, 
and to lessen the irritability of the bowels, laudanum may be 
advantageously combined with it. The oleaginous mixture is a 
good formula for their combination ; of this we give half an 
ounce every two hours, till it begins to act on the bowels.* Rhu* 

* In giving the oil mixture, it is important to select such a formula as will 
render it agreeable, or at least not disgusting to the stomach. The following is 
a good one : — R. 01. ricini, ^i. ; Tinct. card, comp., Ji. ; Aq. cinnam., ^iiss.; 
Gum aca. q. s. ad faciend mist. To the mixture we may add half a drachm, 
or forty minims, of laudanum — in a few cases even a larger quantity. The 
dose is a tablespoonful every two hours, or less frequently if the disease be 
declining. At the beginning of dysentery, when the stomach is quite healthy, it 
is better to give oil as a purgative, in doses of half an ounce, repeated once or twice, 
with ten to twenty drops of laudanum. At the end of the disease the bowels 
sometimes act irregularly, and the oil is then useful in very small doses, that is, 
a teaspoonful. 



514 GERHARD'S CLINICAL LECTURES. 

barb will also answer well as a purgative, and when the active 
symptoms have declined, the spiced syrup answers better than 
any other remedy. Venesection is sometimes required in acute 
dysentery, when the pulse is strong and corded ; but we have not 
found it necessary in any case which has occurred in this hospital 
during the present year. The epidemic character of the disease has 
not been of the violent inflammatory character, which is a cardinal 
point in the diseases of the mucous surfaces, and seems necessary 
to the perfect cessation of the disease. I would not have you to 
misunderstand me, the term restoration of the secretions has been 
much abused and used vaguely. It means simply, in this case, to 
bring about the natural secretions of mucus, &c., in place of the 
diseased ones of blood and lymph. A certain set of remedies tend 
directly to produce this effect, and by restoring the natural secre- 
tions, they not only prove that the disease is ceasing, but they con- 
tribute to its cessation by producing depletion in the most effectual 
way, that is, through the natural emunctories of the part. Cups and 
leeches to the abdomen, along the course of the colon, are also 
frequently advisable ; the latter may also be applied around the 
anus, for the purpose of drawing blood from the hemorrhoidal 
vessels, and relieving the tenesmus. Warm fomentations are very 
often beneficially employed. But these measures, however im- 
portant, cannot alone be relied on for the cure of the disease ; w^e 
must restore the secretions to their healthy condition. This is a 
principal, though not the only object for which we employ calomel, 
"with opiates, &c. The action of opium in dysentery is peculiar ; 
in the first place, it allays the local pain and general irritability ; and 
secondly, it quiets tlie spasmodic movements of the intestine, and 
thereby facilitates the process of cicatrization. But it may like- 
wise produce bad effects ; it tends to lock up the bowels, and 
prevent the discharge of the morbid secretions. To obviate this 
disadvantage we seldom use it alone, but combine it with castor 
oil, calomel, or ipecac. It may sometimes, however, be employed 
singly, either at the commencement or towards the close of the 
disease; but never during the height of the inflammation. Opium 
is also used by injection. In this city, opiate injections in dysen- 
tery have not been much employed till within the last few years ; 
and in the country their use is still very limited, but in this hospital 
we are in the habit of using them very largely. From twenty to 
forty drops of laudanum may be administered in this way, but not 
more, for dangerous consequences from time to time result from the 
frequent employment of large quantities of so powerful a narcotic, 
particularly when given by the rectum, in which mode of admin- 
istration its action upon the brain is more irregular than when 
given in any other way. We usually inject twenty drops of 
laudanum mixed with a small portion of mucilage, every, two, three 
or four hours, according to the severity of the tenesmus and the 
effects of the remedy; thus, if the stools cease, or if the mind 
becomes confused, dull, or the patient sleepy, its use should be 



DYSENTERY. 515 

suspended. There is still another way in which opium may be 
employed in dysentery ; that is, by means of poultices sprinkled 
with laudanum, and applied to the abdomen, or to the anus.* 

Of the other remedies employed in dysentery, ipecacuanha, as 
we have already mentioned, is among the most useful. It is used 
either singly or combined with calomel or opium. A very effectual 
method of administering it, is in combination with extract of gentian 
and blue mass. This combination originated with Mr. Twining, 
and has been extensively and beneficially employed in India. It 
generally produces vomiting at first, but in a short time this effect 
ceases. I tried it largely in one epidemic; its administration was 
followed by nausea and diaphoresis, and a considerable alleviation 
of the symptoms. It sometimes failed, but was generally successful. 
The proportions are, six grains of ipecacuanha, four of blue mass, 
and five of the extract of gentian. 

Various other remedies have been employed in acute dysentery. 
They are principally antiphlogistics, such as saline purgatives, calo- 
mel in large doses, &c. These will doubtless answer in many of the 
ordinary cases of the disease. 

Malignant dysentery is a form of the disease requiring consider- 
able modification in the treatment. It occurs for the most part in 
hospitals, ship, camps, &c. We had an epidemic of it in Philadelphia 
in 1837, and some cases in 1838; it was so violent and rapid in its 
progress as sometimes to produce gangrene of the intestines in two 
days. It is attended with great prostration of the vital powers ; 
subsultus tendinum, and various other signs of debility and nervous 
disorder. All modes of treatment will frequently fail in this form of 
the disease. In the epidemic of 1837, we found it necessary to resort 
to stimuli, tonics and astringents; as wine or brandy, cinchona or 
cascarilla, with the early use of kino, catechu, or chalk. Opium was 
also employed as a stimulus. 

Another variety is the subacute, of which we have an example 
in the first case above detailed. It occurs mostly in persons above 
the age of forty ; and often appears to be the eflfect of irregular habits, 
or of the gradualdeclineof the powersof life. In these cases, besides 
a regulated diet, we find Dover's powder to be the most eflfectual 
remedy; it succeeds better than mercurials alone, but it may be 
combined with them, especially the hydrargyrum cum creta, 
which is one of the mildest and best. I generally give it in 
three-grain doses every four or six hours. Cases of sub-acute dys- 
entery are unfrequent in summer, being most commonly met with 
in the fall. We have had many cases of it in this hospital; they 
have been principally confined to the lunatic wards — a circum- 
stance which is explained by the debilitating effect which a dis- 
ordered mind has upon the system. 

Besides the remedies already spoken of, the acids have been largely 

* This is very useful when the anus and rectum are too irritable to bear the 
mechanical action of an injection. 



516 GERHARD'S CLINICAL LECTURES. 

used in the treatment of dv-sentery. This practice originated in tro- 
pical climates, where lime-juice, vinegar, and other vegetable acids 
were employed. The use of the mineral acids was mainly intro- 
duced by Dr. Hope, whose mixture of nitrous acid, camphor and 
laodaoum, has been of late years so extensively used in bowel 
diseases. It often produces the best effects, but will not answer in 
the sloughing form of the disease. It proves most effectual in the 
sub-acute variety, and sometimes in the acute, after the severity of 
the case has declined : but in the ordinary cases of acute dysentery, 
the benefit produced by this mixture is very problematical. The 
dose is about half an ounce every two or three hours. 

The acid practice is founded upon a peculiar change in the symp- 
toms of the disease which occurs in dysentery. The stool and saliva 
become extremely alkaline, and even the urine and perspiration loss 
to a certain extent or altogether their excess of acid. In giving the 
mixture I have usually continued its administration until the exces- 
sive alkalinity of the secretions diminished or altogether ceased. 

Chronic dysentery is another form which we frequently meet 
with. We have a case of it at present in a woman who has been 
sufleriDg with it for six or seven weeks. There was griping 
in the region of the transverse colon, but durincr the last week it 
has been slight; there have been three discharges in the last ten 
or twelve hours : the skin is dry and harsh ; the patient is much 
emaciated ; this form of tfie affection, indeed, produces more ema- 
ciation than any other disease except cancer. Chronic dysentery 
may last for years, and produce extensive ulceration or sloughing; 
and when even checked, is very liable to return. 

Treatment of Chronic Dysentery. — We must rely principally 
upon a regulated diet, of such a nature as will best agree with the 
patient ; for most persons farinaceous articles answer best, while 
others require animal food. Of the remedies to be employed, the 
best are opium and ipecacuanha with calomel, in minute doses. 
The nitrate of silver is often useful. In many cases, travelling by 
land or sea, particularly the latter, has operated very beneficially, 
by producing a general alteration and improvement in the system. 
This has been found to be particularly the case in the dysentery 
of the East Indies. Sea bathing or sulphur baths are also of great 
beoefit. 

From the preceding remarks you will understand that our treat- 
ment of dysentery must vary exceedingly in the different forms of 
the disease. The success of the treatment will, therefore, be vari- 
ous in different epidemics. In the malignant, sloughing dysentery 
which occurs in camps, &;c,, the mortality is generally great, while, 
in some epidemics, it is comparatively triffing ; we should not form 
a general opinion of the character of the disease from observation 
of a single epidemic, and still less, can we estimate the success of 
our treatment, unless it has been tested in various epidemics and in 
di^rent years. A multitude of remedies are often prescribed and 
used with great benefit in the treatment of the disease ; the limits 
of this lecture wiU prevent me from even mentioning the greater 



DYSENTERY. 517 

part. of them, but they will be in general suggested by the peculiar 
symptoms of each case, and you will often succeed, in the most 
obstinate cases, by attending to some apparently unimportant par- 
ticulars, such as tlie condition of the skin, or some slight change in 
the diet or mode of life of the patient. 

In laying so much stress upon mercurials, I do not wish you to 
understand that I am in the habit of administering these remedies 
carelessly, or with unnecessary frequency. On the contrary, I 
would not use them in dysentery when mild purgatives will cure 
the disease readily ; it is only in severe cases that I prefer the 
mercurial treatment, which is unquestionably the most effectual and 
most rapid means of getting rid of the disorder. There is no 
necessity for producing decided ptyalism ; a slight action upon the 
gums is sufficient to test the effects of the remedy. 

I have explained to you the anatomical lesions at length, because 
your prognosis is, in severe cases, to a great degree, founded upon 
their extent, and you will perceive that a complete cure can only 
take place when the ulcerations of the intestine are healed. 



LECTURE XL 

Sub-acute dysentery (continued) — Pathology and treatment. .^Phthisis pulmonalis. 

I SHALL bring forward to-day a case of the sub acute form of 
dysentery, and afterwards several cases of phthisis, for the purpose 
of illustrating some of the various modes in which this disease 
commences. 

The case of dysentery is one of a class not unfrequently met 
with during the winter months, in which not only the bowels, but 
the mucous membranes generally, are affected. The patient is a 
man of nearly fifty years of age, and an habitual drunkard. A 
fortnight since he had an attack of delirium tremens, the symptoms 
of which continued during several days after his admission into 
the hospital. After an exposure to cold recently, he w-as seized 
with bronchitis, and the affection of the bowels for which he is at 
present under treatment. The alvine discharges have been very 
frequent, sometimes several in the course of an hour; the pain was 
constant, but much more moderate than it usually is in the more 
acute variety of the disease. The character of the stools equally 
shows that it is not a case of acute dysentery ; they consist of ordi- 
nary thin, fecal matter, mixed with mucus, but at no time has 
either lymph or blood been present. This case is a very good ex- 
emplification of the nature of the discharges in sub-acute dysentery, 
and the changes which occur in them at different periods of the 
disease. At first they are either sero-mucous, or thin and fecu- 

44 



518 GERHARD'S CLINICAL LECTURES. 

lent : subsequently their consistence and appearance become altered, 
and they present the characters. observed at the present stage of 
the case before us. Blood and lymph are very seldom to be found; 
but in place of them, there is sometimes a grumous, fetid matter, 
resembling the scrapings of a disorganised intestine, which evidently 
results from partial sloughing of the bow el. 

Although the stools differ so strikingly from those of the acute 
form of the disease, sub-acute dysentery is still an inflamimatory af- 
fection ; but the degree of action is moderate, on account either of 
the debilitated condition of patients labouring under it, from old 
age, or irregular habits, or of the epidemic constitution of the sea- 
san. A constitution of this sort, indeed, appears to prevail at 
present, imparting to epidemic diseases a tendency to assume more 
or less of the characters of the case which we are considering. 

The principal features of the case are as follows. (Complete 
notes were not preserved.) 

J. G., admitted November 25th. The bowels are loose; there is 
cough, with whitish expectoration ; patient much debilitated. The 
oleaginous mixture was administered, and a small quantity of 
milk-punch was allowed. 

2Qth. The punch discontinued. 

2Stli. Dysenteric symptoms more severe; twelve discharges 
from the bowels in the course of five hours ; stools thin and watery, 
with very little feculent matter, but very fetid ; slight pain on pres- 
sure over the abdomen ; cough continues ; mind confused and agi- 
tated. Six ounces of blood taken by cups placed over the colon, 
and the following combination prescribed : 

R Pulv. Ipecac, et Opii, gr. vj. 
Hydrar^. Submuriat. gr. j. 
Ext. Krameriee, gr. v. M. 

To be repeated every three hours. Blisters also applied to the 
abdomen. 

22tli. The Dover's powder and rhatany in the above pre- 
scription were diminished to three grains each, and the calomel to 
one-eighth of a grain. It was found necessary to reduce the 
Dover's powder, because it produced some symptoms of nar- 
cotism ; that is, contraction of the pupil, and confusion of mind, 
without diminishing the frequency of the stools. When such a 
state of things occurs, you must either discontinue opiates, or re- 
duce the quantity administered ; else the narcotic may accumu- 
late in the system, and cause the patient to sink suddenly and 
almost imperceptibly. In the earlier stages of acute dysentery, 
opium may often be given very largely without producing its cha- 
racteristic effect. A case of this variety occurred a few years 
since in one of the resident physicians of this hospital. He was 
attended by Dr. Horner and myself, and the quantity of opium was 
gradually increased to thirty grains a day before the least effect 
was produced. But in the sub-acute form we cannot employ such 



DYSENTERY. 519 

large quantities with safety, and the remedy should be withheld, 
or its dose diminished, as soon as it produces its specific effects. 
You must recollect, too, that even in the acute form of the disease, 
you must give it very cautiously ; for mischief may in any case 
result from it, if administered in a careless or rash manner. The 
rule is, to increase it gradually, and watch carefully its effects; 
suspend it altogether, or diminish it greatly, the moment you find 
any signs of narcotism. 

The Dover's powder and calomel have been the active remedies 
used in the treatment of this case; the extract of rhatany has been 
productive of no very decided benefit. The good effects of mer- 
cury in this disease, (as remarked in a previous lecture,) coincide 
with the occurrence of sliglit ptyalism, — which I find, upon ex- 
amination, to have taken place in the patient before us. If it pro- 
cures no amelioration of the symptoms at this characteristic period 
of its operation, mercury should be discontinued ; and in all cases 
wdiere there is sloughing of the mucous membrane, and a gangre- 
nous fetor of the discharges, its use should be avoided, as it 
then undoubtedly tends to aggravate the severity of the disease. 

You must have remarked that stimuli were employed in the 
early treatment of this case. The patient came in much debilitated 
from the effects of delirium tremens and previous dissipation, and 
a small quantity of milk-punch was therefore allowed. Jn all cases 
of this disease, indeed, in which there is an enfeebled condition of 
the vital energies, it is necessary to use stimuli. This is particu- 
larly true of the malio^nant or sloughing variety of dysentery, be- 
tween which and the sub-acute there is an intimate connection. 
The latter has a constant tendency to pass into the former ; and 
from what has so frequnntly occurred in camps and hospitals, I have 
no doubt that the present case would assume the malignant form, if 
there were many of a similar character in the wards at the same 
time. If such a change should supervene, it would be necessary, 
as I have already remarked, to discontinue the use of mercurials, 
and to rely principally upon Dover's powder and stimuli. 

The cupping in this case produced only moderate benefit, where- 
as the blister operated very advantageously. It is one of those 
instances of moderate, but obstinate iiiflammatory action, to which 
blisters are so peculiarly adapted. Cupping or leeching would be 
better in the more violent and acute cases of dysentery. 

The woman who was brought before you two weeks since as a 
case of acute dysentery, and was treated with mercurials, is now 
quite well. The man who was labouring under the sub-acute form 
of the disease, at first improved considerably, by the use of Dover^s 
powder and astringents, but afterwards sank again, and died on 
the 28th inst. The results of the post mortem examination are as 
follows, and show the cause of death. 

I now present to you the lesions met with in the intestinal 
canal. 



520 GERHARD'S CLIMCAL LECTURES. 

The mucous coat of the rectum is of a bluish colour, and soft- 
ened. As we pass up the colon, we find extensive ulcerations, 
some of which are cicatrized. There is a large cicatrix near the 
sigmoid flexure ; the newly formed membrane is thin and bluish ; 
the old membrane, on the contrary, is much thickened, and to a 
still greater degree are the cellular and muscular coats. Farther 
up the ulcers are scattered about, of small size; the mucous mem-- 
brane softened. Near the ccecum the morbid changes are of more 
recent "date; the mucous membrane is highly injected, and patches 
of lymph are here and there observed. The ulcers are in the acute 
stage of their progress; they are of a rounded form, and are seen 
to have commenced in the follicles of the intestine. We have here 
exemplified the diflferent appearances in the acute and chronic 
forms of dysentery; in the upper part of the colon, where the 
former condition prevailed, the mucous membrane is of a bright 
red colour, as in acute inflammation of this tissue generally ; but 
in the lower part, where the disease had become chronic, the colon 
is bluish. This examination also illustrates a remark which I made 
in a former lecture, that dysentery usually commences in the 
lower portion of the colon, and proceeds upwards in its course. 

The disease has also passed into the ileum, which is in a^' state 
of acute inflammation. There are bright red spots and patches of 
lymph, scattered over the mucous membrane, for some distance 
from the ileo-coecal valve. The glands of Peyer are altogether or 
nearly intact ; in which circumstance you perceive a sti'iking dif- 
ference from the inflammation of the ilium which occurs in typhoid 
fever. This acute inflammation of the small intestine, supervening 
in the* course of the dysentery, was the immediate cause of death. 
The mucous membrane becomes gradually more healthy as we 
ascend, but is more or less softened. 

The stomach also presents marks of inflammation. At the 
splenic extremity the coats are very thin,, and much softened ; this 
condition was in a great measure produced by theaciion of the 
gastric juice, which had become altered in constitution, and exces- 
sively acid ; the membranes at this point have an acid smell, and 
produce an unusually powerful reaction upon test paper. Through- 
out the remaining portions of this viscus the coats are white and 
opaque, from an alteration both in the fluids and the structure. 
There are dark red patches in several places. ]\ear the pylorus 
there is a puckering of the mucous membrane, produced by a cica- 
trix. This membrane is generally softened, but the colour is not 
particularly reddened. The coats of the pylorus are thickened 
and indurated, and there is a scirrhous formation in the cellular 
tissue; its fibrous character is, however, not yet distinctly marked. 
The symptoms produced by scirrhus of the pylorus, are difficulty 
of digestion, and vomiting from time to time, which may be so se- 
vere and repeated as to produce death. It may be remarked that 
these scirrhous aflfections are frequently developed in constitutions 
where the diathesis has been latent, by depression of mind, particu- 



PHTHISIS PULMONALIS. 521 

larly in old persons. This is illustrated by the instance of Napo- 
leon; and I recollect an equally striking case occurring in a Swiss 
emigrant. 

The liver is also affected in the present case, but lesions of this 
organ accompany dysentery far more frequently in hot than in 
cold and temperate climates. Its colour is a pale yellow, and it 
appears to be in the first stage of that alteration called the fatty 
degeneracy. The tests of this condition are the greasy appear- 
ance of the scalpel when drawn through the substance of the liver, 
and the bright fiam.e produced by burning a piece of paper which 
has been moistened with the fatty fluid. The acini are also ob- 
served to be very distinct, and surrounded by vessels, producing 
an appearance of great vascularity and incipient inflammation of 
the liver. The fatty degeneracy in this case was probably pro- 
duced by the habitual intemperance of the patient, and subsequently 
increased by the dysentery. 

The spleen, which is so often found greatly enlarged and soft- 
ened in various diseases, is here nearly of the natural size, but the 
texture is softened. The cause of this change in the spleen is not 
well understood, but it appears to be in some way connected with 
an alteration of the blood. The spleen probably performs an im- 
portant part in the formation of this fluid ; but what the precise 
office is, cannot be yet ascertained. 

From this examination you will perceive how readily the most 
extensive ulcerations of the mucous membrane of the intestine will 
cicatrize, provided the muscular coat is not exposed by them. 



PHTHISIS PULMONALIS. 

I next proceed to bring to your notice several cases of phthisis 
pulmonalis, with the view of exemplifying some of its modes of ori- 
gin ; — this is the more appropriate, as the present season (Novem- 
ber) gives rise to few acute diseases. 

Case 1st. — You may recollect that this man came before you 
on the 23d inst., with many symptoms resembling those of inter- 
mittent fever. Since that time the skin has continued hot, with 
occasional sweats ; the pulse has usually beaten one hundred and 
sixteen in the minute; yesterday, ninety-six; it is also quick and 
irritalDle, jerking, and easily felt, but small and not corded. This 
character of the pulse is often important as a diagnostic sign; it 
occurs in chronic diseases, or in acute diseases gradually passing 
into a chronic state, accompanied by a general disorder of the 
system. It is most frequently observed in incipient phthisis, par- 
ticularly when this disease is attended by pleurisy. The respira- 
tion is also, much more hurried than natural, being performed from 
thirty to thirty-six times a minute. Cough frequent; expectora- 
tion thin, white, and small in quantity ; tongue at present some- 
what pale, and gradually cleaning. The respiration is resuming 
its natural character in the lower part of the right lung, owing to 

4-1* 



522 GERHARD'S CLIXICAL LECTURES-. 

the decline of the pleurisy ; but it. remains rude in the upper lobe 
of the lung; a sign corresponding to the tuberculous cf)ndition of 
the part. The action of the heart continues exaggerated, and the 
second sound is still absent. The difficulty of walking also -con- 
tinues, but in a somewhat less degree : it is dependent on an acute 
affection of the spine. 

The treatment of this case has consisted in the application of a 
blister to the cardiac region, and the administration of digitalis and 
Dover's powder, in the proportion of one-third of a grain of the 
former to three grains of the latter, the dose being repeated four 
times a day. Considerable advantage has resulted from these 
measures; the inflammation which had existed being in a great 
measure overcome., and the inordinate action of the heart dimi- 
nished- The digitalis and Dover's powder were given particu- 
larly with a view to the latter eflect, and to allay the irritability of 
the pulse. This cornbinaiion sometimes produces a dryness of the 
mouth, and of the alimentary canal generally, which is unfavoura- 
ble to the due performance of the digestive functions: but it is by 
far the best mode of administering these remedies. 

I have introduced this case as an example of tubercular disease 
commencing with pleurisy. The tubercular deposition seems to be 
a result of the inflammation, as truly as are its ordinary conse- 
quences, effusion, adhesion, &c. In most patients the latter condi- 
tions would be the only eflbcis of the inflammation-;, but in the 
present case there existed a cachectic condition of the system, 
predisposing it to the -development of phthisis: hence this disease 
followed as a consequence of the inflammation. The inflam- 
mation which thus produces phthisis, may be seated in any of the 
tissues of the lungs: thus, it may be a bronchitis or a pneumonia, 
as w^ell as a pleurisy. But it usually afiects a serous membrane; 
therefore, pleurisy is more frequent than the other pulmonary in- 
flammations preceding: phthisis, just as peritonitis also is often the 
primary lesion in tuberculous deposits in the peritoneucn. But these 
cases of inflammatory phthisis are by no means so frequent as 
those which commence gradually and slowly. Of this more com- 
mon form we have an example in the next case. 

Case 2d. — The patient, who is a printer, has for a long time 
had a slight cough, and other sympton)s of incipient phthis4s. 
During the last summer, there was a threat aggravation of all the 
symptoms, accompanied by a slight inflammation of the bronchial 
tubes; and the patient is now scarcely able to leave his bed. In 
this case, it is evident that the inflammation w-as the consequence, 
not the cause of the phthisis, as in the preceding case. With re- 
gard to those cases of phthisis which I suppose to be caused by 
inflammation; it may be argued by those opposed to this view of 
the origin of the disease, that the phthisis existed, but in a latent 
form, previously to the commencement of the inflammation. But 
those cases- are exceedingly rare, in which the disease does not 
declare itself, either by some, symptoms^ or by physical signs. 



PHTHISIS PULMONALTS. 523 

Hence, I feel compelled to believe, in contradiction to my former 
opinion, tliat phthisis may arise from inflammation, occurring in 
constitutions predisposed to the formation of tubercles. 

Case 3d. — This woman has had a slight cough for four years ; 
about three months since, after exposure to wet and cold, the cough 
and other symptoms were greatly aggravated. These circum- 
stances are sufficient to show that, in this case also, the inflam- 
matory symptoms supervened in, the course of the phthisis, instead 
of preceding it. 

Case 4th. — This woman also has had a cough of four years' 
standing, which became very bad during the summer ; after work- 
ing in an exposed situation. During the last week there have been 
flying pains under the ribs of the right side. These pains arise 
from the slight and shifting pleurisy so often met with in cases of 
tubercular disease. These pleurisies are generally dry; that is, unat- 
tended by effusion of serum. The expectoration is copious ; the sputa 
are in round masses, and of the kind called, from this circumstance, 
nummular; they usually sink in water, but sometimes float from 
their containing particles of air; they consist of pus, mixed with 
mucus, and sometimes a portion of broken-down tubercular matter. 

In both these women, the skin has assumed a dusky, earthy 
colour,, entirely distinct from the paleness which accompanies it ; 
this hue is almost peculiar to phthisis. The sclerotica has that light 
blue tinge which is so frequently met with in constitutional cases 
of phthisis. The appetite has remained good ; indeed a good appe- 
tite, persisting for a long time in a patient aflfected with cough, and 
gradually becoming thin and pale, is one of the most constant indi- 
cations of commencing phthisis pulmonalis; in many cases the appe- 
tite is morbidly great. One of the patients is jaundiced. This 
probably arises from a fatty degeneracy, of the liver, accompanied 
by enlargement; a condition very frequently occurring in this- 
disease; more particularly in female patients. The jaundice arising 
from this cause must be carefully distinguished by the practitioner 
from that which depends upon primary affections of the liver, and 
is totally unconnected with any disease of the lungs. I have seen 
many cases of phthisis in which the liver was supposed to be the 
sole cause of the mischief.. It is true, that in a large proportion of 
these patients the liver was fatty, but this condition arises from the 
phthisis, ajid is neither a primary lesion, nor one in itself of much; 
importance. 

Case bth. — This man has been very recently admitted into the 
hospital. He is^ much emaciated, and has had a cough for four 
weeks ; the disease is therefore probably phthisis.. This probability 
is rendered almost certain by the respiration being very deficient 
under one clavicle, and feeble under the other also. But there are' 
as yet no signs of the existence of a cavity. The patient's account 
of the manner in which the disease commenced^ isthis: After hav-- 
ing been engaged at hard labour, out of doors, during the day, he- 
was awakened from sleep in the night by a sudden, fit of coughing. 



521 GERHARD'S CLINICAL LECTURES. 

and hemoptysis ; in a short time he discharged in this way a pint 
of blood. The hemoptysis lasted several days ; but for the last 
three weeks the sputa have contained no blood, but only a frothy 
matter. This is an example of the hemorrhagic variety of phthisis. 
The hemorrhage with which the disease commenced arose from 
the mucous membrane of the bronchial tubes. In such cases the 
hardening of the pulmonary tissue, from the deposition of tubercular 
matter, does not generally commence early in the progress of the 
disease ; or rather, it does not soon proceed to a high degree of 
induration in any particular portion of the lung. 

The patient is a shoemaker: and we may remark that shoe- 
makers and printers are particularly subject to phthisis, from the 
confined and sedentary nature of their occupations. His constitu- 
tion has always been delicate ; but he has never before had cough 
or pain in the chest, except after occasional exposure to cold. Imme- 
diately previous to the present attack, he was in the enjoyment of his 
usual degree of health. 

Case 6lh. — The patient is, like the last, a shoemaker by trade, 
aged 42. He has had cough for nearly two years, but it has been 
generally unattended with pain ; there has been merely a sense of 
oppression at the lower end of the sternum. In February, 1838, 
he had an attack of pleurisy, which left behind it the usual 
signs of contraction of the chest. He had no cough previously to 
the attack of pleurisy, except for a short time, about six months 
before, and occasionally during spells of intermittent fever. The 
case, therefore, appears to be one of the inflammatory variety of 
phthisis, having been preceded, as in the first of these cases, by in- 
tiammation of the pleura. 

Cr/5e 7th. — This is another example of phthisis commencing 
suddenly, w'ith an attack of inflammation. The patient, a man 41 
years of age, has had cough for eighteen months ; it began after he 
had been working at the engines at a fire : had previously been a 
stout, healthy man, and had never had a cough of any duration. 
The attack w^as one of considerable severity, but the patient was 
not confined to bed by it ; he did light work for a year afterwards, 
but for the last six months has been unable to perform any kind of 
labour. He is much emaciated, and presents all the signs of con- 
firmed phthisis. 

The cases of phthisis arising from inflammation are much more 
frequently found in men accustomed to hard labour than in others, 
and especially in those past the age of five and thirty. In younger 
persons, especially females, the disease is more frequent, and more 
commonly begins in a slow and insidious manner; inflammation 
may, and often does occur in these cases, but then it is strictly 
secondary, and depends either upon the irritation of tubercles in the 
lungs, or the accompanying fever. 

There are cases in which phthisis becomes a local disease only 
at a very late period, remaining for a long time constitutional, and 



PHTHISIS PULMONALIS. 525 

apparently dependent, partly on the nervous, but, in a greater de- 
gree, on the vascular capillary system. 

Case 8th. — There are three modes in which phthisis commonly 
commences: first, slowly and gradually, indeed almost impercepti- 
bly ; secondly, preceded by inflammation; thirdly, commencing 
with a sudden attack of hemoptysis. This case is an instance of the 
third variety of the disease — the liemorrhagic. The patient en- 
tered last Saturday ; he is a weaver by trade. This employment 
is a frequent predisposing cause of phthisis, from the circum- 
stances in which weavers are placed. They work in close rooms, 
much the same way as shoemakers and printers, and fatigue exces- 
sively the thorax. There are other circumstances which aid in 
producing this predisposition in weavers; such as long confinement 
in one position, the dampness of the cellars in which they generally 
work, and the breathing of an atmosphere loaded with irritating 
effluvia, which arise from the woollen and cotton goods. The 
patient had been in good health previously to the present attack ; 
had never had a severe cough for any length of time, and had been 
temperate in his habits. His parents are still alive and healthy, so 
that the predisposition is probably not a hereditary one ; though 
instances are occasionally met with in which consumption passes 
by one generation, and is transmitted from grandfather to grandson, 
without any indications of its presence at the intermediate point. 
The account given by the patient of the manner in which he was 
attacked, is this : — In February last, while engaged at work, he 
was suddenly seized with spitting of blood ; in the course of a fort- 
night he discharged in this way a very large quantity of blood ; he 
thinks it amounted to six quarts, — but this estimate is, no doubt, 
much exaggerated. At last he coughed up a large coagulum of 
blood, by which he was nearly suffocated. From this time the 
hemoptysis ceased, but the cough continued without intermis- 
sion ; the sputa are whitish and muco-purulent. About five months 
since, he began to be weak and emaciated, and has become more 
and more so ever since. Chills also commenced with the cough, 
and have constantly accompanied it up to the present time. This 
is, therefore, another of those cases of phthisis which simulate in- 
termittent or reinittent fever at their commencement, and of which 
I have already spoken in the two preceding lectures. The tuber- 
cular fever, causing this resemblance, occurs in the earlier stages 
of phthisis, and is truly an irritative disease. Sometimes it assumes 
the remittent type. I have known two cases of this sort amongst 
my own acquaintances, which were mistaken for remittent fever, 
and treated as such; but, after some time, tlie true nature of the 
affection was explained, by the clear development of the local 
signs of phthisis. In the present case there would have been little 
difficulty in the diagnosis, for the hemorrhage would have made 
the characterof the fever clear. But, in the majority of cases where 
hemoptysis does not precede the tuberculous disease, you will be 
often aided greatly in your diagnosis by the characters of the fever. 



526 GERHARD'S CLINICAL LECTURES. 

The patient has also suffered from profuse night sweats, and 
here we have a circumstance which distinguishes this fever fron: 
hectic. In the latter, the sweating is not so profuse as in the for- 
mer ; but the chills, on the contrary, are more severe. The patient's 
appetite has been bad for four or five months ; he has had several 
attacks of diarrhoea, continuing two or three days at a time. 
Diarrhoea is a common attendant of phthisis pulmonalis, and gene- 
rally arises from the deposit of tuberculous matter in the small in- 
testines simultaneously with the same process in the lungs; but the 
frequency and duration of its attacks vary greatly in different cases. 
You have rem.arked that the patient was seized with hemoptysis 
while at work ; it is in this way that it often begins, — suddenly, 
and while the chest is exposed to some strain. 

Hemorrhage from the lungs, occurring in this sudden manner, is, 
in most cases, a sure sign of phthisis pulmonalis. It may some- 
times arise from other causes, as disease of the heart, congestion of 
the lungs, or a mechanical cause, such as a strain ; but in five cases 
out of six, in men at least, it is followed by the local signs of tubercular 
disease. In women, however, it is not so valuable as a diagnostic 
sign ; for in them it may follow suppression of the menses, and 
may, in fact, become a vicarious discharge. Though hemoptysis 
may arise, as I have said, from a sudden muscular effort, when 
there are no tubercles in the lungs, — yet, in the majority of such 
instances, they either exist already, or there is a tendency to their 
formation ; for whenever such a tendency exists, the bronchial mu- 
cous membrane will bleed from very slight causes. I recollect an 
instance in which the hemoptysis w^as caused by jum.ping over a 
wall about five feet in height, and was followed by all the signs of 
phthisis ; and another in which it occurred from lifting a gate which 
had fallen. The tubercular diathesis, therefore, predisposes to 
hemorrhage from the lungs. It is true, that not a few cases of 
hemoptysis abort, as it were, before the tubercles are secreted to 
any amount; but when w^e find that the majority of patients in 
whom this symptom occurs, are afterw^ds affected with confirmed 
phthisis, it is perfectly consistent with the facts to believe that the 
hemorrhage coincides with a condition of lungs which favours the 
tuberculous secretion, and which had in many cases given rise to a 
limited deposit of tubercles before the discharge of blood took 
place. 

Of the tubercular fever, w^hich is an attendant of the disease in 
the present case, I have spoken more fully in the preceding lectures. 
The other general symptoms present nothing peculiar. The ema- 
ciation, you perceive, is considerable, and is accompanied by that 
dirty, earthy hue of the skin, (more especially of the face,) which 
you have seen in several other patients. 

The local signs are — 1, cough; 2, expectoration: this at first 
consisted of mucus, aflerw'ards becom.ing muco-purulent, with por- 
tions of broken down tubercles ; 3, dulness on percussion under one 
of the clavicles, with mucous rhonchi, and a commencing cavernous 



PHTHISIS PULMONALIS. 527 

respiration. These last signs indicate the stage of the disease ; they 
show that there is ah'eady sonrje softening of the tubercular matter. 
This fact is also proved by the character of the sputa. 

Case 9th. — This patient has been a labourer on the canal. Be- 
fore the present illness he never had a cough, or any other sign of 
pulmonary disease. He has been sick for two years: the attack was 
gradual, and was produced by taking cold. Since that time there 
has been constant cough and expectoration ; the matter of the sputa 
is at this time muco-purulent, and somewhat nummular, and begins 
to be characteristic of this disease. Emaciation has been apparent 
for eight months : before this attack, the patient was a stout man. 
The skin is dry, pale, and dusky. There has been one attack of 
diarrhoea. There was fever, with profuse night sweats, but no 
chills : it is therefore a modified form of hectic. At present there 
is not much fever — pulse 94. The expectoration consists of round 
masses floating in a thinner liquid, with small pieces of tubercular 
matter: at first it was mucous, then muco-purulent. The sputa 
takes its shape from the cavities in which it is found. We shall 
presently see that when these cavities are very large, the nummular 
character is no longer present. There has been no hemoptysis until 
two nights since, when about a spoonful of blood was discharged. 
Such small quantities are not important ; they may arise from irri- 
tation of the bronchial membrane, and it is only when hemoptysis is 
considerable, that it becomes a sign of importance, and also patho- 
gnomonic of phthisis. 

Case lOtk. — This patient was brought before you at the last lec- 
ture, as an example of tuberculous disease, coinciding with inflam- 
mation of the serous membranes. Since that time, the breathing 
has continued much oppressed; tongue dry and red; pulse, 95 to 
104; bowels constipated. The vesicular murmur has become more 
distinct on both sides of the chest. There has been an increasing 
pain in the pra)cordial regions, with a bruit cle souffiet of the heart; 
respiration frequent and high. Yesterday, for the first time, I dis- 
covered a grating or creaking sound of the heart, indicative of 
pericarditis ; the creaking being produced by lymph into the peri- 
cardium. The two surfaces of this membrane rub against each 
other, chiefly at the beginning of the diastole of the heart, and a 
grating sound is produced by the spiral movement of the heart oq 
its axis, during the dilatation of the ventricles. The patient, you 
will recollect, was first attacked by pleurisy ; since then, pericarditis 
has supervened, with more or less endocarditis. This case is, there- 
fore, a good illustration of a circumstance to which I called your 
attention when I first brought it before you ; the connection between 
phthisis and inflammation of serous membranes. This patient has 
inflammation of all the serous membranes of the chest, occurring 
in succession. The pleurisy has declined as the pericarditis 
supervened. Besides the signs already mentioned, the existence of 
pericarditis, attended with eff'usion, is indicated by feebleness of the 
impulse of the heart, flatness on percussion, (extending over a larger 



528 GERHARD'S CLINICAL LECTURES. 

space than that occupied by the natural dulness of the heart,) and 
pain on pressure or percussion. The latter symptom, however, is 
not always present in pericarditis ; in any of the serous membranes, 
in fact, inflammation ma}^ occur without any of the ordinary signs. 
But in this patient the flatness extends to at least double the usual 
spaces, and there is very decided pain at the region of the heart, 
which is increased by slight pressure, but is aKva\'s more or less 
felt. The dyspnoea in this case is dependent partly on the pleurisy, 
partly on the pericarditis. The pulse is not invariably altered in 
inflammation of the heart, or its membranes; it is principall}^ af- 
fected in endocarditis, which gives rise to more or less obstruction 
of the valves. In the present case, there is excitement of the pulse, 
and slight irregularity. 

I shall now show you some cases of gangrene of the lungs, and 
bronchitis, the symptoms of which more or less resemble those of 
phthisis, and the diagnosis becomes, therefore, frequently difficult. 

Gangrene of the lungs is by no means a frequent disease, it is 
oftener met with in hospitals than in private practice. It resembles 
phthisis, inasmuch as it produces softening of the pulmonary tissue, 
and, consequently, the fornmtion of cavities. It diflers from it in 
the fetor of the breath, and expectoration. The local signs, at the 
commencement of the disease, are imperfect. 

The causes of gangrene of the lungs are cold, an epidemic ten- 
dency of the atmosphere, intemperance, and depressing circum- 
stances generall3\ In most cases, it arises from direct exposure, 
but sometimes it comes on gradually, and appears Jo be part of a 
general disease; that is, it depends on a vitiation of the fluids, in 
the same way w ith dry gangrene, of which I have shown you an 
example. 

Case. — The patient is a boatman, forty years of age. He had 
enjoyed good health till about tw^o months before his entrance into 
the hospital. At that time, being engaged at, his occupation on the 
Schuylkill, he fell into the river, and was with difficulty saved from 
drow'uing. He felt extremely cold, and could not speak for twenty 
minutes, but no sign of active disease followed for two weeks, other 
than feebleness and chilliness. Then a cough began, accompanied 
by pain in the lower part of the right axillar}^ region ; the sputa 
have never contained blood, and have been fetid from the begin- 
ning ; appetite has been bad throughout; the patient continued to 
work regularly until November 30th ; but since that time he has 
been unable to perform any kind of labour. The treatment, pre- 
viously to his entrance into the hospital, consisted of venesection, 
and the application of a blister to the right side of the chest. 

The patient was admitted December 6th. At that lime the 
symptoms were as follows; slight emaciation ; a duskv hue of the 
skin; slight flushing of the face: dilatation of the nostrils; skin 
warm; pulse 104, thrilling, moderately resisting; respiration 22, 
high and laboured ; expectoration thick and homogeneous, of a dirty, 
grayish colour, and very fetid. On the right side, anteriorly, respi- 
ration vesicular throughout, with traces of the mucous rale, hurried 



GANGRENE OF THE LUNGS. 529 

and harsh at the summit of the lung. On the- left side, vesicular, 
with traces of both mucous and sonorous rhonchi. Posteriorly, on 
the right side, vesicular in upper lobe, hurried, and very feeble; in 
lower lobe, scarcely any vesicular sound; at the upper part, deep- 
seated, cavernous respiration, and imperfect pectoriloquy. Percus- 
sion gives a flat sound in the lower two-thirds of right side poste- 
riorly ; clear anteriorly. The signs, therefore, indicated a cavity 
in the lower lobe of the right lung, with an engorged condition of 
the surrounding tissue, accompanied by pleurisy. The treatment 
consisted in the use of chloride of soda, given in' doses of twenty 
drops four times a day, with nourishing diet. Quinine, porter, and 
brandy are often necessary ; the indications being to correct the 
fetor of the breath and expectoration, and support the system, while 
nature effects the elimination of the gangrenous tissue. A number 
of palliatives, such as opiates at night, will doubtless occur to you ; 
but you should be sparing of depletory measures ; they are rarely ne- 
cessary, except when there is severe pleuritis near the gangrene; 
and these should be limited to local bleeding, or, still better, to 
blisters. 

Gangrene of the lungs is to be distinguished from phthisis by 
these circumstances: it usually begins suddenly, and runs its course 
rapidly ; the skin presents a more decidedly dusky hue in gangrene 
than in phthisis ; and the breath and expectoration are always fetid 
from the commencement of gangrene. The prognosis of the two 
diseases is also very different. In gangrene, it is not necessarily 
unfavourable; from one-third to one-half of the cases recover; in 
phthisis, on the contrary, our prognosis is almost always unfavour- 
able after a cavity is formed. When gangrene tends to a favourable 
termination, recovery generally takes place in a few weeks. Any 
improvement in the symptoms of phthisis, on the contrary, is very 
gradually and slowly effected. 

There are two kinds of expectoration met with in gangrene of 
the lungs. The most common is blackish, and resembles an inky 
sediment. The other kind, of which we have an example in the 
present case, is a grayish, frothy fluid, having some resemblance to 
yeast, with a fetid odour, which you may perceive is like that of 
putrid oysters. This, though the least common, is the most favour- 
able variety of sputa. It is generally discharged in very large 
quantities — amounting, sometimes, to a pint or a quart daily. 

I have frequently described, in my lectures, the progress of cure 
in gangrene. When the sphacelated portion is thrown off, a cavity 
is formed, lined with the usual pus secreting false membrane, which 
gradually assumes the character of a mucous membrane. We 
shall watch the progress of this case, and keep you informed of the 
result. 

The next case is one of bronchitis. The patient is a labourer, 
aged 35 years. He entered the hospital on the 2d instant, having 
been ill for two weeks. He was seized with cough, and pain along 
the sternum ; in the course of a week, he began to expectorate a 

45 



530 GERHARD'S CLINICAL LECTURES. 

muco-purulent matter, containing no blood ; during the most of 
the time he has been confined to bed. These signs indicate an acute 
disease, which might be mistaken for the acute form of phthisis. 
It is distinguished from it, by the absence of the irritable, jerking 
pulse of phthisis, described in our last lecture, and also, by the ab- 
sence of the local signs of tubercular deposition. Thus there is no 
flatness on percussion under the clavicles ; and the mucous rhonchus 
is heard in the sound of respiration throughout the lower lobes of 
both lungs. But though bronchitis is thus distinguished from phthisis 
in the commencement, both by the general and local signs, yet it is 
very apt to terminate in the latter disease, and we ought always to 
anticipate such a result when it is prolonged, and occurs in young 
persons. 

The next case is a complication of phthisis and bronchitis. The 
patient is a boatman, 38 years of age, of intemperate habits. He 
has been sick for three months, and unable to work during the 
whole of this time ; his illness was caused by falling into the canal : 
the next day he was seized with shivering and cough, unaccompa- 
nied by pain : the expectoration consisted of mucus mixed with 
pus, but no blood. On the 4th instant he entered the hospital, and 
the symptoms were as follows: — There was abundant mucous 
rhonchus throughout both lungs, passing in certain portions into the 
sub-crepitant, while at the summit of the left lung, the percussion 
is dull and the respiration extremely bronchial. There is a quick, 
irritated pulse, some emaciation, and a dry, husky skin. The sputa, 
although not nummular, are more purulent than is usual in cases of 
bronchitis. The dyspnoea is much greater than in most cases of 
phthisis or uncomplicated bronchitis. 

This case began in the form of bronchitis: phthisis was deve- 
loped subsequently, and the two diseases are now co-existent. This 
state of things is of frequent occurrence, particularly at advanced 
periods of life. At an earlier age, when phthisis is developed in 
the course of a bronchitis, it is apt to commence more suddenly, 
and run its course more rapidly than in the present instance. The 
patient, you perceive, is but slightly emaciated, and will probably 
get comparatively well : that is, the disease may continue for years, 
with slight cough, &c., but may not shorten the patient's life ; the 
cavity in the lung remaining, but lined with a healthy membrane. 
I have known several cases of such comparative recovery from 
this form of disease ; and the chances of long life are not afterwards 
apparently affected by it. 

I repeat that phthisis pulmonalis may commence in several dif- 
ferent forms : 

1. It may commence slowly and gradually. This is the most 
common mode of origin, and is generally met with in cases where 
the tubercular diathesis is hereditary. The first symptoms of the 
disease are slight cough and expectoration ; the local physical 
signs are not present until a more advanced stage. 

It is very clear that in most of these cases the phthisis is no- 



PHTHISIS PULMONALIS. 531 

thing but a mode in which the general tuberculous disorder naani- 
fests itself, and that the disease can scarcely be considered local, 
although the largest deposit of tubercles is in the lungs, or perhaps 
the oniy deposit. In many of them no antecedent cause can be 
detected, in others something has produced a debilitating effect 
upon the constitution, such as grief, indifferent diet, confinement, &c., 
and the natural tendency to phthisis is called into action, or a new- 
disposition to it is developed. 

2. Phthisis may arise from inflammation. This variety is most 
common in robust persons, and is likewise, in most instances, de- 
pendent upon hereditary pi'edisposition, which imparts to inflam- 
mation a tendency to terminate in the formation of tubercles. The 
most common seat of the inflammation preceding phthisis, is some 
one or other of the serous membranes; and the tubercles may at 
first be deposited either in the serous membranes alone, in the lungs, 
or in both. The mucous membrane of the bronchial tubes may 
likewise be the seat of the inflammation; but phthisis beginning in 
the latter way, is more commonly met with in old persons, than 
that which begins by the serous membranes. 

Inflammation performs two distinct parts ; in the first it is properly 
the cause of the tuberculous deposition, which may occursome time 
after the inflammation, or take place during its progress. In the 
second, the secretion of tubercle is attended or followed by an acute 
inflammatory action in the organs, but the cause of the tubercles 
cannot be said to be the inflammation which attends their secretion. 

These inflammations often present some peculiar features, even 
when there is no actual deposit of tubercles. Thus, a slow inflam- 
mation, with an abundant secretion of mucus, will often attack the 
mucous mem.brane of the nasal fossse, or the upper portion of the 
bronchial tubes, and then pass into phthisis. These slow, obstinate 
inflammations, are strictly scrot^ulous, as much so as those of the 
large joints — coxalgia and white swelling; and yet they exercise 
only an indirect influence upon phthisis. 

3. l^\\e liemorrhagic v^vvQiy. In this, hemoptysis, whether pre- 
ceded by a violent eflbrt or not, constitutes the first symptom. 

4. There is a fourth form, which is by no means uncommon in 
certain climates, and is met with occasionally wherever the disease 
shows itself. The patient suffers, at first, not from a disease of the 
lungs, or from any tuberculous disorder, but from dyspepsia, chronic 
disease of the liver, or some other affection of the abdominal vis- 
cera, either of an acute or chronic nature. During the course, or 
at the termination of these diseases, the tuberculous attack com- 
mences and developes itself in the lungs, because these organs are 
especially subject to tubercles from a peculiar law of the economy. 
In climates where the diseases of the abdominal viscera are very 
frequent, phthisis is thus obscure at first, because its symptoms are 
blended with those of the original disease. The same thing is true 
of dyspepsia, which often masks the early stages of phthisis, espe- 
cially in those cases in which the patient does not labour under 



532 GERHARD'S CLINICAL LECTURES. 

simple dyspepsia, but under that variety which is connected with a 
scrofulous constitution. 

But these different forms of phthisis, though differing so much in 
their origin, after a certain period present the same character ; they 
are all attended by emaciation, cough, expectoration consisting of 
pus and softened tubercular matter, hectic fever, and all the other 
signs which mark the more advanced stage of the disease. The 
progress of phthisis is most rapid w^hen produced by inflammation 
of the serous membranes, especially in young subjects ; it is less so 
when preceded by bronchial inflammation. The hemorrhagic 
variety is likewise rapid in its course; the slowest of all is that 
which is constitutional and hereditary. All of these forms are 
liable to be confounded with other diseases; thus, the first may be 
mistaken for simple serous inflammation ; the second for bronchitis ; 
the third for hemorrhage arising from other causes. 

We might multiply the varieties of phthisis almost to an inde- 
finite number, but the preceding are the most important, and may 
be considered as the landmarks in the study of the disease; under 
one or other of these classes, all other forms may be included. 
There are likewise other tubercular affections, not commencing in 
the lungs, and only implicating them secondarily; but phthisis pul- 
nnonalis is by far the most frequent form in which the tubercular 
diathesis developes itself in adults. 

I will conclude the lecture by showing you some very interesting 
pathological specimens, which illustrate this subject. They are -the 
lungs and intestines of a subject who lately died of phthisis in its 
most aggravated form. I could only refer to the case at the last lec- 
ture ; the patient, a young man, being then so feeble as to render it im- 
proper to bring him before you. The physical signs, during life, 
indicated the existence of a large cavity in the left lung: many of 
you have heard the cavernous, amphoric, and gurgling sounds of 
respiration, which were extremely distinct. In the course of his 
illness, the patient also had tubercular diarrhoea. 

You will at once recognise the existence of a cavity in the upper 
lobje of the left lung, by the falling in of itsparietes as I hold it up. 
This whole lobe, indeed, is converted into a mere sac, nothing of 
the normal structure remaining, except the pleura, and a thin layer 
of the tissue of the lungs on its inner face. The large size of this 
cavity accounts for the great distinctness of the amphoric respira- 
tion in the last stages of the disease. The cavity is lined by a false 
membrane, and contains a considerable quantity of muco-purulent 
fluid mixed with particles of tubercular matter. The muco-puru- 
lent matter is a secretion from the false membrane; and the contents 
of the cavity differ from the expectoration only, in not containing 
saliva, which is mixed with them afterwards. The sputa in this 
case were not of the nummular form, of which I showed you a 
specimen just now, for some days before the death of the patient, 
because the cavity was too large for their formation. You will 
notice several bands or bridles passing from one side of the cavity 



PHTHISIS PULMONALIS. 533 

to the other : these consist of blood-vessels, which have resisted the 
ulceration longer than the surrounding tissue : sometimes, however, 
they are opened by this process, and hemorrhage is the result, which 
is often instantly fatal. The rest of the left lung is infiUrated with 
grayish tubercular matter to such an extent, that scarcely a trace 
of the healthy tissue can be found. The tubercles are partly soft- 
ened, and small cavities are seen here and there: these gave rise to 
the gurgling sound of respiration. 

In the right lung, the lower lobe is in a comparatively healthy 
condition. The tissue of the upper lobe is engorged with blood ; 
tubercular masses are scattered through every part of it ; they are 
of a yellowish-white colour, and no signs of softening are yet 
perceptible. 

In order that you may see the connection between the lesions 
and their physical signs, I will read some extracts from the notes 
of the case. — Nov. 4th. Respiration throughout right side expan- 
sive and full, but a little harsh. Left side, cavernous respiration 
with distinct pectoriloquy, most evident near the sternum, about the 
second rib. — Nov. 24th. Anteriorly, very loose gurgling, with 
cavernous respiration throuu;hout the whole of the left side. 
Puerile respiration in the right side. Posteriorly, on the left side, 
very loose mucous rhonchus, with gurgling; throughout; but there 
is a little vesicular murmur near the scapula. Respiration rude in 
upper third of right lung. — 27th. Left side, anteriorly, respiration 
amphoric above ; loose gurgling in the lower third. Posteriorly 
(same side), gurgling and cavernous respiration in the lower half, 
and at the summit; in the intermediate space, respiration distinctly 
cavernous, but mixed with a vesicular murmur. 

I vvill now examine the intestinal canal. The mesenteric glands 
are enlarged, of an irregularly rounded shape, and are entirely 
converted into tubercular matter. This condition of things, when 
the tuberculous deposit is confined to the mesenteric glands and 
adjacent parts, constitutes the disease called tahes mesenterica. In 
most cases of this sort, there are likewise tubercles, either in the 
peritoneum, or the follicles of the intestine : here they are found«in 
both situations. 

Large intestine. — In the colon there are some ulcers in the 
follicles, with slight inflammation of the mucous coat. Near the 
rectum are innumerable ulcers of small size, which appear like so 
many distinct points, because they have commenced in the separate 
follicles. 

Small intestine. — Near the ileo-coecal valve are numerous ulcers, 
evidently commencing in the glands of Peyer. Some of these 
glands still remain, but much enlarged, and containing yellowish 
tubercular matter, which is still of a firm consistence. Here you 
may distinctly trace the changes which take place in the follicles, 
from the first deposition of the tubercular matter to its complete 
softening, and final discharge by ulceration. The other viscera 
were not examined, on account of the short time which remained 

45* 



534 GERHARD'S CLINICAL LECTURES. 

for us to make the examination previously to the lecture. There 
is no doubt, however, that tubercles existed in several other organs, 
particularly the bronchial glands and the spleen, which are amongst 
the most frequent seats of these deposits. 



LECTURE XIL 

Phthisis pulmonalis. — Pathological characters of gangrene of the lungs. 

We have another case of phthisis pulmonalis; some remarks may 
serve to give you some further knowledge of its history and dia- 
gnosis. The case before us is another example of the ordinary 
variety of phthisis, which commences gradually, and without any 
assignable cause. The patient is a printer, forty-seven years of 
age, formerly of intemperate habits, but since the commencement 
of the disease he has been perfectly temperate. Last winter a cough 
commenced, but so gradually that the patient is unable to fix the 
time of its first occurrence ; during the last four months it has been 
much more severe and constant, and accompanied by hoarseness. 
There has been at no time spitting of blood ; the expectoration was 
at first mucous, afterwards muco-purulent and somewhat nummular: 
this change in the character of the expectoration took place about 
the time that the hoarseness comm.enced. The left side of the chest 
is somewhat contracted ; the respiration is cavernous, with distinct 
pectoriloquy. These signs show the existence of a cavity," but it 
seemiS to be rather of an indolent nature. The hoarseness in this 
case is owing to inflammation attacking the larynx, and causing 
thickening of its lining membrane^ and of the vocal cords; this 
inflammation qften passes into ulceration ; it is sometimes painful, but 
often there is scarcely a slight tickling felt at the part. I find on 
rr^aking pressure upon the larvnx, that the patient complains of no 
pain, except just below the thyroid cartilage. This inflammation is 
the result of the irritation of the tubercular matter and other dis- 
charges which pass over the bronchial membrane, and it may take 
place at several different points of the respiratory passages — the 
larynx, the trachea, or the bronchi. This variety of inflammation 
is strictly secondary, and very diflferent from that which occurs in 
the early stages of phthisis, in which the tracheal irritation is the 
cause developing tubercles, and not the result of their softening. 
There is generally considerable soreness attending the inflammation 
when the phthisis is acute ; in more chronic cases it is slight, or 
altogether absent. This inflammation of the air-passages, in the 
cases of which I speak, is secondary; in others, as I have already 
repeatedly remarked, it may precede the development of phthisis. 
The other symptoms in the present case are of the usual kind; the 



PHTHISIS PULMONALIS. 535 

skin is dry and harsii ; there is general emaciation, witli roundness 
and prominence of the ends of the fingers ; the pulse is quick, tense, 
and irritated ; there are chills about the middle of the day, followed 
by fever in the afternoon, and cold sweats at night. The fever, 
therefore, has the regular paroxysmal character of hectic. 

You have now seen cases of several varieties of phthisis, differing 
in their origin and progress; it is time to say something of the 
diagnosis of this affection. The diseases with which it is most liable 
to be confounded, are bronchitis, pneumonia, and pleurisy, whether 
of the acute or the chronic form ; since phthisis, also, may be either 
acute or chronic. It may likewise be accompanied by any of 
these inflammations, and it becomes important to distinguish 
such cases from those of simple inflammation. The diagnosis of 
tubercular disease depends both on the general and the local signs. 
The first circumstance to be attended to, is the general aj)pearance 
of the patient. The frame is emaciated ; the skin is of a pale and 
earthy aspect; there is a restless expression of countenance, in- 
dicating the working of a slow disease, and entirely different from 
the alteration of the features which attends acute disorders. The 
emaciation shows itself very early in the hands and fingers, — the 
ends of the latter retaining their fulness for some time, and ap- 
pearing rounded and prominent ; the nails are likewise turned 
inwards. Emaciation is a sign of great importance in the diagnosis 
of phthisis and other tuberculous diseases ; particularly if you find 
that the patient is losing flesh, although he eats nearly as much as 
in good health. When this sign is conjoined with others indicative 
of phthisis, the diagnosis becomes ahuost certain. The earthy hue 
of the skin is attended by a bluish tinge of the sclerotica, which very 
often occurs in phthisis. 

We likewise observe a change in the circulation. There is a pe- 
culiar fever attending tubercular disease, and characterized by a 
quick, jerking pulse, the result of excessive irritation. This fever is 
accompanied by chills and sweating, — the former being at first 
very slight, while the latter is much more copious than in most other 
acute diseases. This peculiar condition of the pulse and sharp 
febrile excitement, are most important in the diagnosis of general 
tuberculous disease of an acute kind. It is, however, quite as well 
marked when the tubercles are rapidly developed in the lungs, as 
when they are deposited at the same time in several of the organs. 
The observation of these general signs should cause us to suspect 
the existence of phthisis, and lead us to the examination of the local 
signs. If, upon an inquiry into the latter, we are unable to ascer- 
tain the existence of any other disease, we are led, by a process of 
exclusion, to a confirmation of our original suspicions. 

We also derive some important points of information from a con- 
sideration of the predisposing causes of the disease. Thus, the sex 
exercises some influence ; phthisis is rather more frequent in females. 
Age is a more important circumstance: phthisis is most frequent in 



636 GERHARD'S CLINICAL LECTURES. 

young persons, and is rarely met with after the age of thirty-five. 
When it does occur after this period, it generally depends upon some 
accidental cause, as inflammation, &c. The course of the disease is 
another thing to be considered ; phthisis is in most cases slow in its 
progress: the diseases with which it is liable to be confounded are 
more generally acute. 

The last and most important circumstance in the diagnosis of 
this disease, is an attention to the local signs. The first of these is 
usually an uneasy sensation in the chest, very different from the pain 
of inflammation. It varies greatly as to its position, sometimes 
shifting from one side to the other, or felt under the sternum. Pain, 
however, may be present in the commencement of phthisis, when it 
is complicated with intercurrent pleurisy. The cough is constant, 
but rather more severe at night, or early in the morning, than 
throughout the day ; it is at first short, and so insignificant as hardly 
to attract notice, and attended by mucous expectoration; in the 
progress of the disease it becomes loose, and the expectoration is 
muco-purulent and nummular; in a still more advanced stage, the 
cough is very loose, — the expectoration consists of pus mixed with 
softened tubercular matter, and loses its nummular character. 

The physical signs are not obvious at the commencement. The 
first thing observed is generally a feebleness of respiration at the 
upper part of the lungs, which afterwards changes into rudeness; 
this arises from the obstruction of the lung by the tuberculous de- 
posit. We next perceive a crackling sound under the clavicle, 
indicative of the commencement of softening. There is likewise a 
dulness on percussion at the summit of the lung. In the advanced 
stages there is gurgling, with cavernous and amphoric respiration, 
and more or less perfect pectoriloquy. 

There are certain secondary symptoms regu]3ir]y occuvrmgrn phthi- 
sis. One of these is hectic fever; at first the fever attending tubercu- 
lous disease is not hectic ; I have pointed out the difference in a 
previous lecture. When hectic is developed, it is recognised by the 
chills andsweating which accom.pany it ; the flush on the cheeks, &c.; 
it is always paroxysmal. The loss of appetite, and decline of 
digestive power, do not depend upon the deposit of tubercles, but 
upon the fever which attends it ; they difl^er in no way from the same 
symptoms which ordinarily accompany febrile diseases. The diar- 
rhoea of phthisis, however, often depends upon the formation of tuber- 
cles. It is intermittent, very irregular in its character, occurring 
sometimes frequently in the course of the disease, sometimes only 
once or twice. Its immediate cause, in most cases, is the deve- 
lopment of tubercles in the glands of Peyer, which, consequently, 
become inflamed and ulcerated ; but diarrhoea in phthisis may arise 
from the same causes as in other diseases ; in the latter case, its 
symptoms and progress are entirely similar. Hemorrhage is another 
of the accidental or secondary symptoms of phthisis; the blood is 
either discharged directly from the lungs by a slight cough, or it is 
swallowed, and afterwards ejected from the stomach. If the he- 



GANGRENE OF THE LUNGS. 537 

morrhage be profuse, that is, not less than two or three ounces in a 
day, it is considered almost pathognomonic of phthisis, especially in 
males ; in females, it is not so certain as a diagnostic sign, for 
hemorrhages from different parts of the body often arise from sup- 
pression of the menses, &c., and are, in fact, vicarious discharges; 
but in men, as I observed in tlie last lecture, in at least five cases 
out of six, abundant hemoptysis arises from tubercular disease of 
the lungs. The fact that hemoptysis is a very important sign of 
phthisis, has been long known, but Dr. Louis has rendered the profes- 
sion a decided service, by proving that the value of the sign was 
even greater than had hitherto been believed. Many cases of this 
hemorrhagic variety of phthisis terminate in recovery ; it is, in fact, 
the least unfavourable form of the disease, and therefore the value 
of the symptom is sometimes underrated, because in the minds of 
many physicians, the word phthisis and death are considered as 
almost inseparable. This form of the disease is probably less fatal 
than others, simply because the flow of blood relieves, to some 
extent, the vessels of the lungs, and appears to be a natural safety- 
valve, which diminishes the tendency to the tuberculous secretion. 

The case of gangrene of the lungs which I showed you last week 
has since terminated fatally, and I will now present to you the 
results of the post mortem examination. You will recollect that 
I then stated that the disease affected the lower lobe of the right 
lung: it rapidly extended itself, and the patient sank in proportion. 
There is, in fact, no specific treatment by which the disease can be 
arrested; all that we can do is to support the system until nature 
accomplishes the cure, if such is her design. The pathological 
appearances of gangrene of the lungs are closely connected with, 
and explain, the symptoms during life, viz., fetor of the breath and 
expectoration, lividity of the countenance, and the physical signs 
of a cavity in the ciiest. This case occurred in consequence of the 
patient falling into the river : the gangrene probably commenced 
about two weeks afterwards, and had continued for several weeks 
previously to his entrance into the hospital : since that time it has 
been constantly advancing. If the progress of the disorganization 
could have been checked, it is probable that the case would have 
terminated favourably, for the mischief already done was not 
necessarily fatal. You will at once perceive the excessive fetor 
of the lung, and its dark green colour over the lower lobe. As I 
lift it up, the surface of the lung sinks towards the cavity, which 
occupies the greater part of the lower lobe of the left lung. The 
cavity rapidly increased in size during the last days of life, as was 
proved by the enormous quantity of matter expectorated, amounting 
to at least a pint in the course of the twenty-four hours. The 
immediate cause of death, however, was dyspnoea, arising from 
inflammation attacking the heart. 

Pleurisy, in a greater or less degree, always attends gangrene of 
the lungs ; here we have the proof of its existence, in the false mem- 
brane which covers the surface of the pleura. This inflammation of 



538 GERHARD'S CLINICAL LECTURES. 

the pleura, producing false membranes, and adhesions of the lung 
to the ribs, tends to prevent the perforation of the pleura, and the 
discharge of the gangrenous matter into the cavity of the chest. 
From the existence of amphoric respiration, perforation might have 
been suspected in the present instance, had we seen the patient only 
on the last day or two of life: but you now see that no such thing 
has occurred, and that the amphoric respiration was owing to the 
great size of the cavity. The lung is much softened around the 
cavity, and yields readily to the knife. The cavity is large enough 
to hold the fist: it is seated entirely in the lower lobe, having been 
first formed at its upper part : the disease very rarely attacks the 
upper lobe. By an examination of the walls of the cavity, we will 
be able to determine w hether any process had commenced for the 
cure of the disease: when this does take place, it is by means of a 
false membrane which is formed around the cavity, and secretes 
pus and mucus, as is shown by the character of the sputa. But 
here we see no appearance of a false membrane, nor of pus or mu- 
cus : the cavity contains a crangrenous slough, and a quantity of 
the offensive matter which was so copiously expectorated during 
life. The walls are blackish, and gradually pass into the healthy 
lung. The existence of cavities formed in this way, is known by 
nearly the same physical signs as those which are observed in 
phthisis; but the fetor of the breath and expectoration is sufficient 
to distinguish the two diseases, independently of various other cir- 
cumstances. The mucous membrane of the bronchi is inflamed 
in consequence of the passage of the gangrenous sputa over it: in 
some cases this matter is swallowed, and produces severe diarrhoea. 
The upper lobe of the left lung is healthy, with the exception of a 
few miliary tubercles scattered through its summit. 

The right lung became inflamed in the progress of the case. 
The pleura is covered by a false membrane of the consistence of 
cellular tissue, which is very brightl}^ injected. This inflammation 
was one of the causes of death. The substance of the lung is 
healthy, with the exception of a slight engorgement and induration in 
the centre, w^hich probably constitute the first stage of gangrene, 
and a few tubercles in the upper lobe. 

Upon examining the heart, we find traces of former pericarditis. 
in the patches of lymph on the surface of the pericardium, and the 
serous effusion into its cavity. The heart is of the natural size: 
its muscular structure is in the normal condition, and its lining 
membrane is also nearly natural, but not entirely so ; there is a 
slight thickening in the left ventricle, and also of the semilunar 
valve of the aorta. The right side of the heart is frequently found 
perfectly healthy, though the left be greatly diseased : in this case 
we perceive merely a slight opacity of the internal membrane of 
the right ventricle. The valves of the pulmonary artery are quite 
healthy. 

The spleen is enlarged and softened ; this appears to depend upon 
the vitiation of the blood produced by gangrene, in the same way 



PHTHISIS PULMONALIS. 539 

with the livid hue of the skin. The Hver is fatty, and of a lighter 
colour than natural. This fatty degeneration in males is frequently 
the consequence of intemperate habits: it is also very common in 
phthisis, more particularly that of females. In the progress of this 
alteration, the cellular tissue uniting the acini becomes more deve- 
loped than natural, while the acini seem to disappear, their places 
being occupied by fat. 



LECTURE XIII. 

Phthisis puimonalis (concluded). — Cases. — Treatment. 

I WILL to-day conclude the subject of phthisis for the present 
course, by showing you one or two cases of the disease, and say- 
ing a few words in relation to its treatment. I shall occupy the 
remainder of the hour with some cases of cerebral and cardiac 
disease, and the results of a post mortem examination of an indi- 
vidual who recently died of phthisis complicated with serous in- 
flammations of the heart and lungs. 

I will first present to you a case of phthisis, commencing in a 
different mode from any of which I have yet spoken. The pa.tient 
was attacked about two years since with coxalgia, from which he 
has never entirely recovered. The treatment consisted in the use 
of blisters and a seton; the discharge from the latter, after having 
continued for some time, was allowed to cease. About eight weeks 
after, he was seized with cough, which still continues, with other 
signs of phthisis ; for a few days of the period which has elapsed 
since the commencement of the cough, there has also been hemop- 
tysis. The phthisis in this case evidently commenced with a 
scrofulous disease of the hip-joint ; for in two months after the dis- 
charge established for the cure of the coxalgia had ceased, the 
symptoms of phthisis began, and have since progressed in the 
regular order. The scrofulous diathesis, therefore, before affecting 
the lungs, developed itself externally. Cases of this sort are by no 
means rare; the external scrofulous disease may be seated in other 
parts than the hip; sometimes, for example, it occurs in the form 
o{ fistula in ano. An important practical question occurs in rela- 
tion to such cases: Ought we to endeavour to cure the external 
disease ? If we do, there is great danger that the irritation may 
be transferred to the lungs, and lead to the development of tuber- 
cles : on the contrary, if we suffer the disease to proceed unmo- 
lested, the constitutional irritation arising from it may destroy the 
patient, or give rise indirectly to the formation of tubercles in the 
lungs, by producing a condition of the system favourable to this 



540 GERHARD'S CLINICAL LECTURES. 

result. The proper course would seem to be, not to check the ex- 
ternJil disease too suddenly, but, if possible, to subdue it by degrees. 
Some time ago we had a case here, which illustrated the effects 
of an opposite plan of treatment. The patient was first attacked 
with tubercular meningitis ; after recovering from that, he had fis- 
tula in ano ; this was cured, phthisis consequently supervened, 
and the man died. These cases are extremely common, and you 
will see many such in your practice. The case now before us is 
also one in point. The arrest of these external discharges may 
likewise give rise to other diseases, among which are diseases of 
the heart, and inflammation of the lungs; the latter in such cases 
being often of a more chronic character than in ordinary pneu- 
monia. 

Case 2. We have here an example of phthisis occurring in old 
age ; the patient is sixty-two years old. He has been employed in 
one of the oyster cellars of this city, — a situation, from its damp- 
ness, and also its darkness, extremely favourable to the develop- 
ment of phthisis. He has had cough for seven years, but it has 
never been severe till the commencement of the past summer. 
There is now well-marked cavernous respiration, with pectoriloquy, 
and other signs of cavity in the upper lobes of both lungs. Phthisis 
occurring at such an advanced age is extremely rare. But expe- 
rience shows us that no age is exempt from this disease. Tuber- 
cles are found even in the foetus, and at every period of life. They 
are most frequently met with, however, about the fifth year, and 
afterwards from the fifteenth to the twenty-fifth. Cases of phthisis, 
or other tuberculous diseases, occurring in old persons, are much 
more frequently observed in hospitals than in private practice. 

I next introduce these men, formerly patients, but now employed 
in the house, in whom cavities in the lungs have been more or less 
perfectly healed. The first is a case of phthisis, in which a cavity 
became cicatrised after it had continued to a very advanced 
stage, but was reproduced upon a second attack of the disease. 
The patient entered the hospital about three years since, with all 
the signs of a cavity in the right lung; dulness on percussion, cavern- 
ous respiration, &c., were very well marked. He remained in the 
wards for several months, during which time his condition was 
constantly improving: he was then discharged, and was, to all ap- 
pearances, nearly well, — a small cavity, however, still remained, 
with slight cough and expectoration. After he had been out of the 
hospital about five months, he had an attack of intermittent fever, 
which continued for some weeks. After he recovered from the 
fever, he had a second attack of phthisis, or, as it were, a new crop 
of tubercles, for which he was under treatment in our wards. He 
is again much improved, though still feeble. The local signs in- 
dicate a partial consolidation of the lung by the process of cicatri- 
sation; thus, there is dulness on percussion, and a diminution of 
the natural vesicular respiration. These indications of a cicatrix 



PHTHISIS PULMONALIS. 541 

exist where formerly were heard a strong cavernous respiration, 
and all the other signs of a cavity of considerable size. The cure 
in this case, then, is only partial. 

But in the case which I now present to you, there has been a 
complete restoration. The patient, in the year 1835, had an attack 
of gangrene of the lungs, which continued for several months, with 
very fetid expectoration, and all the other symptoms of this aflec- 
tion. The local signs indicated a cavity large enough to contain 
the fist. After a time the expectoration became muco-purulent, — 
a change which indicated an arrest of the gangrene, and the forma- 
tion of a false membrane on the surface of the cavity. The man, 
as you see, is now stout, free from dyspnoea, and in every re- 
spect perfectly healthy. There was no scrofulous vice in the 
constitution, tending to reproduce the cavity, as happened in the 
preceding case. The disease was caused by cold and intemper- 
ance. As the man has now been well for nearly six years, the cure 
may be considered complete. 

You see, therefore, that it is possible to cure a cavity in the 
lungs, however infrequent may be the occurrence of such a result, 
especially in phthisis, Vv/here new crops of tubercles are so liable to 
form. The treatment, in all such cases, is entirely negative; there 
is, in fact, no remedy for the lesion. All that we can do is to palli- 
ate the symptoms, and support the constitution of the patient till 
nature, if she be so disposed, accomplishes the cure. Generally, 
the prognosis after a cavity has been once formed, is altogether 
unfavourable ; we always look for the death of the patient, whether 
the cavity be the result of a tubercular deposition, or of any other 
lesion. But before the cavity is formed, our chances of success 
are much greater. In hospitals, however, our prospects, in either 
case, are far less encouraging than in private practice. We are 
entirely unable to adopt those measures which are most essential 
to a successful issue ; we can only employ medicinal remedies ; in 
relation to food, clothing, air, exercise, &c., the means at our com- 
mand are necessarily very limited and imperfect. In private 
practice, on the contrary, we are enabled more successfully, to 
combat the general disease, by changing, as far as possible, the 
whole constitution of our patients; for this purpose, we direct a 
change of scenes and of climate by travelling, which is our prin- 
cipal reliance in such cases. 

In the treatment of phthisis, you will find that there is great 
practical importance in the classification of the disease into several 
varieties, which I have called your attention to in preceding lec- 
tures. The inflammatory variety may frequently be arrested in 
the earlier stages by the ordinary antiphlogistic means which we 
employ in cases of simple inflammation. In that variety which 
commences slowly and gradually, on the contrary, we derive little 
or no aid from this plan of treatment. The treatment of phthisis, 
therefore, must be as various as the diflferent forms of the disease* 

46 



542 GERHARD'S CLINICAL LECTURES. 

In the ordinary slow cases, we must attempt to change, as it were, 
the whole being and nature of our patient, in the same manner as 
we do with regard to the mental constitution in the treatment of 
insanity. By thus producing a change in the constitution, we en- 
deavour to cause the expulsion of the tubercular vice. For the 
details, I must refer you to the different treatises which have been 
written on the disease. 

It is unfortunate that the treatment of phthisis proper should be so 
limited, that is, as to the strictly curative treatment. If it be inflam- 
matory, it is more immediately within the power of medicine, and 
a removal of the local inflammation, which is acting as a continual 
irritant upon the constitution, bringing about at last decided phthisis, 
is our first object, and then the patient will often pass little by little 
into perfect health, or he will remain in a feeble condition, which 
requires a change of air, a long voyage, or some other constitutional 
renovation, to remove the remains of the disorder. But if these 
patients be improperly treated, and sufi^ered to remain suffering from 
chronic inflammation, or if they are exhausted by what is termed 
very vigorous treatment, they may readily pass into phthisis. This 
is especially the case as regards chronic pleurisy : a suitable anti- 
phlogistic treatment is necessary, but an eye must always be kept 
to the state of the patient's general health, and the strongest eflx)rts 
should be made to keep up the strength and aid the constitution in 
throwing ofl^ the disease, if already developing itself, or in acquiring 
that vigour which is opposed to tuberculous disease. In such cases 
a mercurial treatment is admissible, and I believe that the safest 
mode in many cases would be to mercurialize rapidly, as recom- 
mended by Drs. Graves and O'Bierne, were it not for the difl^erent 
susceptibility of patients to the action of mercury, which must render 
this mode of treatment at times injurious. It is better, therefore, 
on the whole, to give mercury in more minute doses, and to discon- 
tinue it as soon as a constitutional impression is made. It is impos- 
sible, however, to exercise too much caution as to the use of mer- 
cury in individuals attacked or threatened with phthisis, and from 
my experience in its use I would limit it to the very beginning of 
the disease, when associated with chronic pleurisy, or perhaps pneu- 
monia : for there is a tuberculous inflammation of the lung which 
is slow to resolve itself. 

As to the treatment of the disease, properly speaking, it is so well 
laid down in diflferent treatises upon the subject, that I must restrict 
my remarks upon it to my lectures on the diseases of the chest, 
where the subject is necessarily enlarged upon. 



PNEUMONIA. 543 



LECTURE XIV. 

Pneumonia. — Jaundice. — Tubercular meningitis. — Pathology of laryngitis and 

laryngeal phthisis. 

We have lately had several patients convalescent from acute 
diseases, especially inflammatory affections of the lungs. I shall 
conclude the lecture with a few remarks on the tubercular affec- 
tion of the membranes of the brain, so common among children, and 
with the demonstration of some pathological specimens illustrating 
the history of laryngitis. 

Case L — In the two preceding lectures I spoke to you of a 
man labouring under an acute disease of the lungs, the severity of 
which rendered it improper to remove him from the ward. He is 
now before you in a state of convalescence. This man entered 
the hospital about a month since, at which time he presented the 
signs of pneumonia, complicated with an incipient tubercular affec- 
tion — the latter impressing certain modifications upon the cha- 
racter of the former. Under the treatment which was adopted, 
the patient at first did very well ; but suddenly grew much worse, 
in consequence of the supervention of pleurisy, followed by copi- 
ous effusion. The distress produced by this complication added 
to that immediately consequent upon the proper affection of the 
lungs, and brought the patient to the brink of the grave. The dys- 
pnoea and prostration of the system were extreme. In this con- 
dition of things, a mild, depletive plan was pursued; the great de- 
pression of the recuperative powers of the patient put all active 
measures of the kind out of the question. A single cup was, there- 
fore, applied, and repeated according to the necessity of the case ; 
at the same time the patient was put upon the use of mercury. 

This treatment was soon followed by an improvement in the 
aspect of the case, which, however, was not very decided, until the 
action of the mercury was made manifest by the occurrence of 
slight ptyahsm. From that time, (seven or eight days since,) the 
patient has been steadily improving. But convalescence, in a case 
like the .present, is never 'so rapid as it is in simple pneumonia. 
This is owing partly to the tubercular diathesis of the patient ; in 
part, also, to the abundance of the pleuritic effusion, which always 
requires a certain time for its removal by absorption, more particu- 
larly when it co-exists with pneutnonia or tubercles. The case is 
one of considerable interest, as illustrating the advantages of very 
moderate depletion, and of the judicious employment of mercury in 
certain forms of acute pulmonary disease. In relation to the latter 
remedy, I have repeatedly urged upon your attention, that we 
employ it in acute affections, not for the purpose of salivating our 
patients, but of producing its specific constitutional influence. Its 
effect upon the mouth is the mark of this influence, or of the satu- 



544 GERHARD'S CLINICAL LECTURES. 

ration of the system with mercury; after the slightest possible red- 
ness of the gums is produced, the influence of the remedy cannot 
be rendered more complete and decided, no matter how copiously 
it be given. 

Case 2. — This is an instance of pneumonia so mild as hardly to 
require any treatment. The patient is a man aged forty-nine ; he 
is of robust frame, and has led an active life, having been for some 
years a soldier in the Peninsula : he has generally enjoyed good 
health. He has lately been employed in cutting ice. On the 19th 
he was taken ill; the first sign of the disorder was a chill. This 
was followed by cough, but no pain in the chest; the expectora- 
tion has been viscid from the first, but has never been coloured 
with blood ; at no time has the patient been confined to bed. On 
the 25th he entered the hospital, — and, on examining his chest, 
the physical signs of pneumonia were detected. The following 
pectoral mixture v;as ordered: — 

isc Ext. Hyoscyami, gr. viij. 

Syrup Polyg. Senegae, 5j. 

Mucilao;. Acacis, 5 v. 
Pt. Mist. 

27ih. The hot infusion of eupatorium was ordered. Under 
the action of this remedy, the disease passed off by a copious dia- 
phoresis: the patient is still sweating. He may now be considered 
as convalescent. It would appear, therefore, that only eight days 
elapsed from the commencement to the crisis of the disease. This 
seems to be in contradiction to a rule which I laid down in a pre- 
ceding lecture, viz., that the usual duration of pneumonia is from 
fourteen to twenty-one days. But it is to be remarked, that 
although the general signs indicate the declension of the disease, 
the local signs still exist; there are yet manifest some dulness on 
percussion, and crepitant rhonchus. By the time that these have 
disappeared, the case will probably be brought within the average 
which I have stated. This is the usual course of mild cases of 
pneumonia. 

In cases like the present, no active treatment, and little, indeed, 
of any kind is requisite. Hot diaphoretic and nauseating drinks, 
are the best possible remedies. Such instances of mild attacks are less 
frequent in pneumonia than in most other diseases, and the expec- 
tant and palliative treatment just mentioned, is rarely worthy of 
confidence. But when such cases do occur, a more active treat- 
ment only puts the patient to inconvenience, without resulting in 
adequate benefit. I wish particularly to inculcate this principle, 
that, when a disease is tending to a favourable termination, all 
nieasures of an active kind should be dispensed with ; it should be 
a matter of conscience with the physician not to harass the patient 
with unnecessary applications. An opposite course of practice 
lends, in no small degree, to throw discredit on the profession. 
This hurtful officiousness arises not from any defect or error in the 



PNEUMONIA. 545 

plan of instruction in our schools, but from an idea which is so apt 
to be entertained by every student from the commencement of his 
studies, viz., that every disease is recognised by certain signs, and 
requires for its cure a certain set of remedies. So that whenever 
the symptoms indicate the existence of inflammation, bleeding, 
purgation, and revulsion, at once suggest themselves to his mind. 
It requires experience to teach him that there are, in fact, many 
cases of inflammation, and still more of continued fevers, which 
require no such violent measures. 

Case 3. — In this case we have pursued a plan of treatment 
precisely the reverse of that adopted in the preceding one. Very 
free bleeding and other depletory measures have been resorted to, 
but not with a corresponding amelioration of the symptoms, be- 
cause they were not practiced until the disease had made consider- 
able progress. The patient. Shepherd, was seized with pneumo- 
nia on the 8th inst. ; he was admitted into the hospital on the 18th f 
so that ten days had elapsed before any attack upon the disease 
was made. The treatment was commenced by the abstraction ot 
twenty ounces of blood from the arm ; this was followed by cups 
to the side, which were repeated three times ; the patient was 
also placed upon the use of the infus. eupatorii. Notwithstanding 
these active measures, the disease continued to advance, with very 
slight modification of the symptoms. The combination of opium^ 
digitalis, and calomel, of which I have already so often spoken, 
was then ordered, mainly with the view of obtaining the antiphlo- 
gistic action of the mercury. Two days after his entrance, the 
patient was taken with singultus, which came on at particular 
periods in the day, and continued for an hour or two at each at- 
tack. Hiccough is a symptom of grave import in inflammatory 
aflfections, and is injurious in itself, inasmuch as it serves to exhaust 
the strength of the patient. It seems not to depend directly on the 
inflammation, but on a sympathetic irritation of the nerves of the 
diaphragm. It is a symptom which is more frequently met with 
in some seasons than in others; during the past year we have not 
had many instances of it. As it was not quieted by the treatment 
already adopted, assafoetida was ordered with this view; this fail- 
ing, the oil of amber was ordered, in doses of six drops, repeated 
according to circumstances. Under this treatment, the singultus 
gradually subsided, and the disease took a favourable turn. 

At the last lecture I remarked to you that the duration of this 
case would probably not be shortened by the active practice which 
had been pursued, and the result has verified the remark. Bleeding, 
however copious, will not cut short an inflammatory disease, 
unless practised soon after its invasion ; a few hours may carry the 
afl^eciion beyond the point at which depletion may cause it to abort. 
After it has passed this point, bleeding, though it does not arrest the 
course of the disease, is stillof use, by palliating its inconveniences, 
and diminishing its tendency to run into fatal disorganizations. 

Little change was perceptible in the condition of the patient 

46* 



546 GERHARD'S CLINICAL LECTURED. 

until the 25th, when he was somewhat better. Oia the 26th he ap- 
peared to be in a state of convalescence. On the 27th this fa- 
vourable change was still more evident. The face was pale and 
sunken; I have already stated that this subsidence of the features 
after the fulness and flushing produced by inflammatory excitement, 
is one of the best signs of convalescence. The pulse had fallen 
from ninety-six to eighty ; it was soft and tremulous. The respi- 
ration had also fallen from thirty to twenty in the minute. No 
doubt therefore could exist as to the fact of the patient's convales- 
cence ; the simultaneous subsidence of the respiration and the pulse 
rendered it perfectly certain. On the contrary, if the pulse had 
become slower^ while the respiration retained its frequency, we 
should have concluded that the patient was in a much worse con- 
dition. 

The duration of this attack of pneumonia was nineteen days, 
which is within the average which I stated in my remarks upon 
Case 1. Pneumonia, in fact, has a natural duration, and one princi- 
pal object to be aimed at in its treatment, after the disease is es- 
tablished, is to prevent accidental circumstances from interfering 
with the natural tendency of the disease to terminate at a certain 
period. 

Jaundice. — The patient, aged 45, entered the hospital on the 
23d inst. He had always enjoyed good health until last summer, 
when he had an attack of dysentery. On the 22d, after exposure 
to wet and cold^ he was seized with cough, and the same evening 
he had a chill, attended with pain at the xiphoid cartilage. On the 
23d he was jaundiced ; the skin, conjunctiva, and urine, were of a 
deep yellow, and every object appeared to his sight to be of the 
same colour ; the skin was moderately warm ; there was no head- 
ache, but pain and tenderness in the right hypoehondrium, v/hich 
obliged the patient to lie on the left side ; expectoration was slight ; 
p)ulse moderately fulL Venesection, cupping over the region of the 
liver, and a diaphoretic infusion, were ordered 

24th. Patient more jaundiced ; pain had extended to epigas- 
triun) ; shght signs of bronchitis observed. Cups repeated, and an 
infusion of senna, with sulphate of magnesia, ordered. 

26th. Patient now complained of headache, and vertigo, de- 
pression of mind, &c. Bleeding repeated. 

From this tinie the symptoms rapidly abated, and few remains of 
the disorder are now perceptible. The skin is only slightly coloured 
on the breast ; the vision has become natural ; the skin is moist ; it 
has never been hot, however, at any time in the progress of the 
case. 

The most prominent symptom of this case, besides the alteration 
in the colour of the skin, was the tenderness in the right hypochon- 
driac and epigastric regions, accompanied by dulness on percus- 
sion. It was inferred from these signs that the liver was congested, 
and slightly inflamed. Inflammation of the liver is by no means a 
^common occurrence in the winter season. The prevailing inflam- 



JAUNDICE. 547 

matory diseases are those of the Jungs, heart, and fibrous tissues of 
the extremities ; the abdominal viscera are more rarely affected. 
But this man's previous history affords a very sufficient reason for 
the occurrence of hepatitis in his case. Last summer he had an 
attack of dysentery; now, a severe dysentery hardly ever passes 
through its course without involving the Uver in a greater or less 
degree. There is, therefore, a strong presumption, that this man's 
liver was at that time affected ; it was naturally left in a condition 
favourable to the return of disease^ upon the occurrence of the 
usual causes. This circumstance determined the deleterious im- 
pression of cold to the liver rather than to the lungs. 

Jaundice depends on a great variety of causes. When acute, as 
in the present case, and dependent on congestion and slight inflam- 
mation of the liver, it is in general easily cured. It yielded in this 
case to bleeding, cupping over the liver, and saline purgatives. 
Mercury was not employed at all in ihe treatment : the only cha- 
racter in which it could have been used with propriety was that 
of an evacuant, — and in this case it seemed to offer no particular 
advantages over saline and other purgatives. You will recollect 
that in the numerous instances recently brought to your notice in 
which this article was employed, it was not as a purgative, but as 
an antiphlogistic remedy in certain stages of inflammatory affec- 
tions. 

Headache was an important symptom in this case, and its occur- 
rence induced us to repeat the bleeding. In all cases of jaundice, 
indeed, cerebral symptoms demand particular attention ; for it is 
usually in consequence of the supervention of cerebral affections 
that this disease proves fatal. The cause of this complication is 
the suppression of ihe biliary secretion, the elements of which being 
retained in the blood, act like a poison upon the system, especially 
on the brain. In like manner, urea, if retained in the blood, proves 
deleterious. In fact, all diseases of the liver or kidneys, attended 
with suppression of their secretions, are followed by coma, and 
other signs of cerebral oppression, in consequence of which they 
terminate fatally. It is in this way that the granular affection of 
the kidneys, called " Bright's disease," often proves fatal. When 
the cerebral symptoms are active, the proper treatment is general 
and local bleeding, cold applications, &c. But it is impossible to 
remove them until the bile is eliminated from the blood ; this is 
effected slowly, and by a process of nature. If the symptoms are 
attended with much depression of the vital energies, depletion 
becomes improper, and we have to rely on other means, the most 
effectual of which experience proves to be sinapisms and blisters. 

x\t the last lecture I introduced a man labouring under acute 
laryngitis, upon whom an operation was performed in your pre- 
sence, but without success. This case was one of acute, grafted on 
chronic laryngitis. The affection was originally acute, (having 
commenced about a year ago,) but became chronic, and continued 



aad iiffi ^^s^dsBosw^Ke asaafEffigk-aEaifesfl mllfaE tinffi df iii? EiitraijnE. 
it miffi lii^esiPffis giHfiau » Bfl ifaittllftfe Sun^ ^'sre afiecisil, — bui in 
wiai ^«raT. tbe sigiB meis 1&b» otecnre Id eiiHbie de preciseh' Id 
teermine. Tiie iai^ wcae yBrrJDiff Id the Ejr, bd thai itiere -wbhe 
link duinesfi qd ^^sai^ssawm^ hm. ihe respiratiDii "wh? fesbte ifaroi^b- 
®fll ibe right side, tauil sbbk «a^ft£B ^'a* xiifilmguBiiBd faelo-w. It 
•was iience inferred tbat aie iJmig was cDngested., fad ndtiiiiig ete 
could be umiib <ojil wflifa saw Dertamtr t a« vod ^rill pregBnth' bsb. 
these signs w^s^ vmm^ to ihe rie^^elopmenl of miiiaTT, lubsrcnlur 
^ aim l at,>niffi,j ob ^sesBt sHssB^iaK^, ^^iih CDngestiDii of the Burromid- 
m^ ^ffiBfiK . lite m^EnisOJmi «tf larrngDlomx. pBTforined bj Th. 
Gibsojig jpgm^ox^ mmm jslief ibx the momenl; but lie %«pncsE 
returned •evsrv iime 'fe a-itificia] Dpsning became obstruded, und 
DDt more than baif an faour ^b^jn^d ttefoife tbe -man died vS siMd- 
cation. The operalioD tr^s resorted Id a$ tbe onh' chance 'i£ 
proiongirjg life ; but e^ven if it bad iaeen more succesfitnl for tbe time, 
it couid not, in the «nd, have saved the patient — for an immense 
iiumi>er of grajisii, Bemi-transparent, tubercular granuialiimB, iiad 
:filjed the upper and a part erf ihe -b^^er lobe of the right lung., and 
the upper and a part of the lower lobe of tbe left. But, bad the condi- 
tion of the patient been such as lo aik)w a full examination and 
positive diagnosis, the operation would fitill have been justifiable, as 
tfje onhv means of securuag to the patient a few more iiouTs nr &sws 
Df life.* 

The immediate caise of the interase di^niEa un^er wbicb ite 
patient iaboured, was cedeina of tbe Isn-irK. and inflammation i)f 
ifae trachea and bronchraa. Tie former ofiered a veir gi^ai 
obstacle to the passage of ibe air throngb tbe rima ginttidk — while 
tiffi tractiea and bponchi were lined b^r a lajer of -very -v^iseid nnncuE. 
-wbicb interposed a further Dbstarcle to ite entrance into tbe lungs. 
The matter lining ihe air-passage was ■nstl, properlj speaking, a 
false membrane^ but it was bd deise that ft cDuki be detaciied in 
shreds of considerable lenglii. Ttiere w^s likewise an uksration 
of the lining membrane vi tbe lari'nx, beti^'een the pc^erior e-x- 
tremities of the vocal cords, and exteniiing 1d the -cricDid cartilage. 

This case is one of interest, inasmuch -as it iikifitrales ihe con- 
nexion between larrngitis and ph lb isHs. JLarj-ngitissomelimeE occuTf 
2£ the primarr, sonaetmies as the secondary difease. The latter -^-as 
tfae case m a patient who lately died in tbe female ^ards : du:ing tbe 
prer^rass of a tutiercular affection, she w]ffiB attacked with lar^-ngitis. 
wbicb was indjcaied by the ordinary ^raptoms, di^nosa and 
aphonia. Wi^n iaryngitis dccui^ bs iiffi Drigbial afection, it may 
continue for yeara, attended witb mme ct ]&ss -cdi^ii, iioaraeneffi. 
and dyspnoBa, but without anj' indicalkms of dise^ie in tbe pulmo- 
nary tissue. At last ulceration or^curs : at this point, in a ^^'crry 
large proportion of cases, tubercles are dex'eiii^d in the lui^;s. Ifaa 
this variety of plitfaisic tlie tutffircies ai^ generally graj^b, lEini- 



LARYNGITIS. 549 

transparent granules, of small size, and uniformly diffused through 
the lung. Consequently, phthisis following laryngitis, is one of the 
most intractable varieties of the disease. In all cases where the 
affection of the larynx has advanced to ulceration, we apprehend the 
supervention of phthisis. Almost the only variety forming an ex- 
ception to the rule, is that form of ulceration of cartilages and of 
the mucous membrane which occurs in secondary syphilis. But it 
is easy to discriminate such cases by the general condition of the 
patient, the history of the affection, &c. Besides ulceration of the 
larynx consequent on syphilis, almost always extends rapidly into the 
cartilages. The prognosis of laryngitis is never grave until ulcer- 
ation has occurred : if there be merely thickening of the mem- 
brane, a cure may frequently be effected ; but if ulceration takes 
phice, this result can hardly be hoped for. 

If the dyspnoea should be excessive, and threaten suffocation, an 
operation for its relief is the only resource. There are several 
different methods of performing such an operation. Dr. Gibson, in 
the case which we have been considering, preferred laryngotomy. 
This is usually done by making a transverse incision through the 
crico-thyroid membrane. In France, the operation for croup is 
often performed, and at the present day surgeons generally are in 
favour of tracheotomy. In this operation, a longitudinal incision is 
made into the trachea, which is kept open for the passage of air, 
either by means of a canula, or of a blunt hook applied to each edge 
of the incision. This operation is preferred to laryngotomy ; inas- 
much as it admits of a more extensive opening, through which the 
false membrane may be pulled away. You will find an excellent 
paper on this subject in a late number of the Medical Examiner. 

I now^ show you the larynx and trachea of the man who died 
after the operation of laryngotomy was performed. The lining 
membrane of the larynx was at first highly injected ; but by macer- 
ation in water, the blood has been almost entirely washed out. 
However, you can still perceive the oedematous state of the glottis. 
This oedema was produced by the effusion of serum under the 
mucous membrane, in the same manner that it is effused from the 
surface of inflamed serous membranes. The mucous membrane is 
softened : at the posterior part of the larynx is a large ulcer, and 
many smaller ones are scattered over the remaining portions of the 
larynx, as well as the upper part of the trachea. The mucous 
membrane of the trachea, like that of the larynx, was highly in- 
jected. The epiglottis is slightly thickened at its lower part. In 
the crico-thyroid membrane, you see the opening made by the ope- 
ration ; it is not quite so large, in fact, as the natural opening of 
the glottis; it therefore easily became obstructed by the viscid 
secretions which filled up the air-passages. 

The upper lobe of the left lunsr, and all the lobes of the right 
one, contain an in:imense number of small, gray, semi-transparent 
granulations. In the right lung, they are so numerous as to have 
almost obliterated its vesicular structure. A tubercular deposition 



«f this kind: ne^fo* aecur^ exrr^t in scnXi^ phthisa. The ri^ht lun^ 
m likewise coft^ated, partieuiariy' at the La wer part, aver which, 
the arepiraac rhurrchiia wns heard duriruj life. At the 3uraniit af 
Ajehin^isa cicatnasd cavity;, containing a mass of caicar2oaa 
HBitter- The aurraunding parenchyTia is pucker^ and contracted 
By the dcatrrx- and the adjacent uleura. is covered hj adhesiana 
Ihese appearances indicate ihe farmer existence af tubercles ; these 
iRore prabahiv" d^osated at the same time the chronic laryngitis 
accurrei, and were cemoved by the ahsorptton of their ininraLrnafc- 
Vsc. the calcareous portLQC remaimng behind and canstLtuting the 
white maa^a wbich yon here see. 

Ha-e are the Lungs fane ther patient, who entered the hcroitsd 
in. the last 3tage af an ihiais. and died within forty-eig :. I 

^ow Uiem to you far the purpose of contrasting the ea. - : the 
latio: stages of the afection. Ar the suinmit of one krag is a large 
canity, and in that ai the appoaitB one are nunieraus anall granii- 
Iiisian^ of recfflit origin. 

Wheal the tidiercuiar zranuiations are depoated in great numbers 
thrauiiii the pulraunary tissue, the disease is almost always acjite, 
and, in met, is iuenUcal with wnat is atten called the •* gallccmg 
danaumption.'' The termination of this variety, which is amost 
always fiitai,. occurs in two ways : in the one Sie patient dies of 
dyspnoea,, and you find, as m the present caae^ the lungs excessively 
eangesied^ through all that portian of them in which the granuiations 
WDS: deposited. The death thea actually takes place by su^ocation. 
I have seen some examples of it r one at the irst was twelve years 
^u, when I was a resident aupii of this hcspitaL A black, who 
had aeen labouring under the disease for some time, with much. 
flDys^ncea, called to us one day while making the visit, diat he was 
Srangiin^ and died almost immediately l the lungs were excessivrfy 
congested, and almost atufed with tiiese granulations. 

In most cases, the disease pastes on to sattenins at the summit, 
sa: least at tiie lungs, while the rest of the tissue is engorged and 
filled with the granuiations. In these cases there is high fevar. 
swearing, and generady intense dyspnoea. The cough, however, 
may be vs-y aisrbt. Ton will find the respiration genearally feehfej. 
wad iiie chest leas sonorous than usual. 

Tliere lately occurred a disease at the brain, which I am acciden- 
tsriLy prevented fi:am^owing you, and which was interesting as 
SBEL illustration at an afection of which I may perhaps speak more 
feily at a future tiraK, — tuoercuiar diseases of the membranes of the 
Icain.. The ea^^ was tiiat of an adult. On opening the cranium, 
tidiercuiar granuiations were found beneath tiie membranes, both on 
tbe superior surface and base of the brain ; in the hiiervals Left by 
them, the membranes were injected,, and covered with lymph. The 
affietttion prohafaty tbllowed the development of tubercles in the lungs: 
tfee ejGirainariair was not extended to these argana. The deposition 
«f tubercles mder the membranes of the brain was tollcwed by acute 
mfiamraaiion, which resulted hi etFusion, and soixenins of the cerebral 



TYPHUS AND TYPHOID FEVER. 55 1 

substance. This was indicated by rigidity and paralysis of the 
extremities; muttering deUrium: subsultus tendinum ; contraction, 
and afterwards dihitation of the pupils; distortion of the mouth. 
The occurrence of symptoms of meningitis in the course of tuber- 
cular phthisis, may be considered sufficiently certain evidence of 
the development of the affection of which I am speaking. In 
children it is indicated by the signs commonly described as belong- 
ing to acute hydrocephalus. This disease, so called, which is fre- 
quent from the age of two years up to puberty, is neither more 
nor less than tubercular meningitis; the inflammation is usually 
attended with efi:usion into the ventricles or on the surface of the 
brain, and from this circumstance the ordinary appellation of the 
disease is derived. But the efi^usion is altogether an accidental 
matter; and so is the softening which sometimes occurs. It is the 
tubercular deposit, and the concomitant inflammation, which con- 
stilute the essential characteristics. 



LECTURE XV. 

Typhus and typhoid fever. — Symptoms. — Treatment. 

In the works of many writers on the continued fevers of Great 
Britain and Ireland, you will find that the only distinction admitted 
by them, as to the nature of these diseases, is that of the degree of 
severity of the symptoms. Thence the common division into 
typhus mitior and gravior ; terms indicative only of the greater 
or less intensity of these disorders. In France no efficient attempt 
was made to trace the distinctive characters of the different af- 
fections classed under the name typhoid until the year 1806, 
when the work of Petit and Serres was published. These writers 
found that in the forms, such as they witnessed at Paris, there was a 
constant anatomical lesion seated in the abdomen and occupying the 
follicles of the ileum, especially the agglomerated patches, or, as they 
are often called, the glands of Peyer, seated near the ileo-coecal valve, 
the mesenteric glands, and the spleen. These alterations were in- 
flammatory, the affection of the glands of Peyer being attended with 
redness, thickening, and often passing into ulceration, while the 
mesenteric glands were enlarged, reddened, and softened, and the 
spleen was enlarged and softened. The evidence of inflammation 
was indeed perfect, except as regarded the spleen, of which the 
lesion might be regarded as dependent either upon inflan)matory 
softening or as the result of an alteration of the fluids of the body. 

The after investigations of Dr. Louis proved this matter much 
more conclusively. In his excellent work upon typhoid fever he 
has shown that the disease is uniform, and accompanied by a 



552 GERHARD'S CLINICAL LECTURES. 

regularly developed series of symptoms, not occurring in a con- 
fused manner, but forming together a well characterised whole. It 
was this uniformity which enabled him to designate the disease in 
such a manner that there is now no difficulty in separating the 
cases of it which are met with from those of the different affec- 
tions classed under the vaguely used terms — typhus and typhoid 
fever. 

In Great Britain, and still more frequently in Ireland, another 
disease, which is endemic in those countries, is called typhus fever, 
and resembles in many particulars the typhoid fever described by 
Dr. Louis. It differs from it in its symptoms, but especially in its 
mode of extension and in its anatomical characters. The latter 
are not fixed and regular ; on the contrary, the organs are diseased 
in so many different degrees, that observation proves that there is 
no one uniform anatomical character, unless it be the condition of 
the blood, which is evidently altered in many cases, and probably so 
in others, in which the demonstrative proof is wanting. The 
lesion of the glands of Peyer is not met with in this disorder, unless 
it be in a straggling case of typhoid fever, classed among the cases 
of typhus; or in a complicated case, which is extremely rare, but I 
believe occasionally met with. 

The deductions of Dr, Louis, as to the anatomical lesions of 
typhoid fever, have not therefore lost any of their value ; they still 
remain true as applied to the disease described by him ; but they 
are not applicable to the English typhus, or, as Dr. Graves calls it, 
the maculated fever. In order to prevent confusion in these terms, I 
have for some years past used the term typhoid fever, as applicable 
to the fever described by Petit and Serres, Louis, and even by 
Roederer and Wagler, and I restrict the terai typhus to the disease 
described by the British writers, and not attended by the intestinal 
lesion. This distinction is gradually passing into common use in 
the United States. At one time I was disposed to adopt the term 
typhus mitior as applicable to typhoid fever, but I found that there 
were many cases and various epidemics of typhus fever in which 
the symptoms of the disease w^ere extremely light and the mor- 
tality inconsiderable, but still the leading characters all remained, 
and the identity of the disorder was in nowise weakened. The 
terms mitior and gravior may, therefore, very properly be used to 
designate merely the degrees of severity of the affection, and 
not to distinguish two different forms of disease ; the former is 
happily the more frequent form ; the latter appears only in a few- 
places, or in close confined ships and hospitals, where a number of 
men are crowded together. 

The symptoms of typhoid fever are not all found in every case; 
that is, some one or more of those which are considered leading 
symptoms may be wanting, but the group of those which remain is 
in every case, or nearly so, quite large enough to identify the dis- 
order. For convenience, you may divide them into distinct groups ; 
first, those of the cerebral and nervous system ; secondly, of the 



TYPHUS AND TYPHOID FEVERS. 553 

skin; thirdly, of the abdominal viscera ; and, lastly of the thoracic 
organs. 

Those of the first series are, loss of strength and prostration, 
which occurs very early in this disease, singing in the ears, vertigo, 
and not unfrequently epistaxis. The pains in the head and limbs 
are not so violent as in the remittent or intermittent fevers. There 
is more frequently chilliness than a regularly defined chill. These 
are usually the earliest symptoms, followed after some days by 
slight diarrhoea and other abdominal disturbance. The brain symp- 
toms increase slowly, the patient becomes dull and stupid ; if the 
disease be violent, he may become comatose. Delirium is not in- 
variable, although it is rarely quite wanting; but if the disease be 
mild, it shows itself only at night, and for a short time. In severe 
cases the delirium is violent, and if this be complicated wnth menin- 
gitis, the patient may fall into the wildest ravings ; it is in general 
much more mild and low, or muttering. In fatal cases coma al- 
most always precedes death. 

In typhus w^e have a different succession of symptoms, and 3(' 
difference in their development. From the very first attack of the 
disease the stupor is the most prominent symptom ; sometimes the 
intelligence of the patient is in some degree preserved, although he 
seems to be in a dreamy, stupid condition, almost inattentive to 
surrounding objects, but still capable of answering correctly and 
continuously when his attention is excited. The recollection of the 
patient after the attack is extremely confused, and the stupor 
resembles in many respects a state of somnambulism. Besides the 
stupor, headache, dizziness, and tinnitus, are all amongst the early 
symptoms of typhus, but the strength is much less broken down 
than in typhoid fever. If the disease advances, the patient becomes 
comatose at a much earlier period than in typhoid fever, and gene^ 
rally dies if the case be fatal of the brain symptoms. Delirium is 
a very frequent symptom ; indeed there are few cases in which it 
is totally absent ; it is almost always of the still, muttering kind, 
except when complicated with inflammatory action of the brain. 
The cerebral symptoms of the two forms of fever differ less from 
each other than many other groups of symptoms, but there is, in 
the majority of cases, a greater diflference in the character of the 
symptoms than is easily described ; especially as regards the stupor, 
which is much deeper and more disproportioned to the other symp- 
toms in typhus than in typhoid fever. 

The external symptoms of the two diseases vary; you have seen 
that both are attended with an cutaneous exanthema, but in typhus 
this is general, extending over the whole body ; in typhoid fever it 
is limited to the anterior part of the trunk, that is, the abdomen and 
thorax, rarely reaching as far as the thighs. The typhous eruption 
consists of a measle-like rash, slightly elevated, of a light red at 
first, but after the second day, or in severe and malignant cases, 
from the first, of a darker tint. The papulae are rounded and vary 
in size, from an almost imperceptible point to the breadth of nearly 

47 



554 GESHAED'S CUSKiAI. lECTUiaSL 

a line. The rash is r : " : ^ t : is, if liie 

term peteeiiisB be confLiji^ ;v ^_: l.j .i. ; -z:^ :: :::•;': r It^^-^ r!:t 

it is frequently called by this term, and in the Vc~ - r 

published in 1837 the word is used in this se: :t It- : _ : : :- 
ally subsides after four or five days, but it is i : : ^ ti t ; 

ten, twelve, or even fourteen days. It appears r 

third day of the fever. There is no other eror: 
liar to typhus ; sudamiDa are, however, : 

about the groins, and other parts where the br^j.. .r ._.„. ^:: z-._^y 
during the hot weather. The measJe-like eruptioii is evidently sm. 
exanthema, and very similar to the papular e: _ •.; : ' t ^ : f: :z 

its development and progress : and, from it; ; _ . . . - 7_ :i. 

Dr. Graves calls the disease the maculated typhus. 

Tbe eruption of typhoid fever is papular, but the spots are rather 
larger, about a line m length, elliptical, more elevated, few in num- 
ber, often not exceeding six or eight, and rarely more than thirty; 
lliey appear a little later than those of typhus, but last about :dje 
same time. The sudamina are much more frequent than those of 
typhous fever, and often appear in two different crops, one early 
in the disease, and an^ - before coovalesceoGe. 

It is not yet settled " t t 3 ny fonm of coiaaiMiOBd fever is m&t 
with which cannot be reierreu to one of these classes : I hax^e mjmM 
seen none. Bat we must remember that some of the symptoms ©f 
typhus occur in many diseases in which the blood is more or ^ss 
altered, such as phlebitis, asthenic pneumonia, &:-c^ and thus sds^ 
be confounded with these diseases, iust as certain stages of Ttendl- 
tent fever are often called by 1":^ ^ ^ ^ f regarded as loeie 
varieties of typhus. B'j! tber? .; ^ z-se crse?the coBa- 

plete series of symptc": : _gn some isoiaiec : :y be naett 

with, in diseases whic„ i^^c.^.e in some respecii ...ziz irvere, i^t 
are without the characteristic eruptions. 

The symptoms connected with other organs vary in the two 
fevers. The abdominal symptoms of typhoid fever are, diarirbffia, 

which is a frequent though not invariab'f 5 " - - ~ ^ ^- 

tympanitic distension, pains in tbe abd: : t i t i ^ - 

gastrium, at others in the ihac fossa. In ;■ - : z — 

symptoms is found, except as a rare and a: : _ : 7 
The thirst and anorexia are common to the two disease; _ . :: r 
former symptom is generally more marked in typhus, tht - t: ..:. 
typhoid fever. 

The thoracic symptoms are but modf ^ " ifi 

fevers. In the typhoid the bronchial : i: : : :..• 

gegted, €ipecially in the smaller tubes. Tue coiige£i. . ; ^ 5 2. 

^^t sil^iiil rhonchus, and may of course pass . 
lis or pneumonia of a severe character. Ib lypfciK ine .^ _. ::r 
also congested, but it is in a different way. Use i':-' - : : : '• 
along the spine seems full of blood ; causing at tir t : : - ; 

rhonchus, but preventing in a great degree the air fi^o:: 
the smaller tubes. This condition of the lungs sbbobs it . 



TYPHUS AND TYPHOID FEVERS. 555 

upon the state of the blood than that of the mucous nnembrane, 
properly speaking, which is only secondarily involved. 

The action of the heart is not violent in either disease; on the 
contrary it is often enfeebled, especially in typhus, in which the loss 
of power of the heart is one of the strongest indications for a stimu- 
lating practice. The pulse" is more frequent in typhus than in 
typhoid fever. The capillary circulation is more or less altered in 
both diseases ; hence the skin is dull and of a dusky tint, and at the 
face is often of a deep red colour, as if excessively congested, and 
the blood circulates slowly through the vessels, especially in typhus. 
The capillary vessels of the conjunctiva are injected in typhus, 
and full of blood, which circulates rather slowly through them; but 
in typhoid fever we have rather a bright eye than the dull, heavy, 
bloodshot one of the former disease. The medical physiognomy of 
the patient, which is mainly dependent upon the capillary circula- 
tion, is one of the best diagnostic signs of the two diseases, but it is 
very difficult to describe. 

There are some other circumstances which are of interest in re- 
lation to this matter. One is, that typhus fever spares no age, is 
more severe amongst the aged and those in middle life than the 
young, and generally prevails as an epidemic, extending itself by 
contagion, or direct propagation, from an infected individual, or still 
more frequently from a mass of infected individuals, to others. 
Typhoid fever, on the other hand, rarely assumes this infectious 
character, and is rarely epidemic, probably it is scarcely infectious, 
except when prevailing epidemically. I never met with a case of 
the genuine typhus in this country before the year 1836, but typhoid 
fever is a common sporadic disease, especially in the northern parts 
of the United States. 1 have seen both varieties in newly-arrived 
passengers from emigrant ships, but rarely in the same ship. The 
typhus attacked a much larger number of patients than the typhoid, 
and was increased in severity in direct proportion to the number 
attacked. In some of these ships the disease was evidently pro- 
pagated from one individual, who contrived to embark while labour- 
ing under the disease, and then those sleeping in the same birth 
with him were the first attacked. The origin of the fever was 
clearly transatlantic in all such cases, and in fact it was merely 
the Irish typhus, carried over to America by Irish emigrants, and 
sometimes propagating itself afterwards. 

The treatment of mild cases of typhus is extremely simple: re- 
garding it, as I do, as a self-limited disease, which necessarily tends 
to recovery unless arrested by some accident, I content myself 
with the simplest measures, acting as it were in the direction of the 
disorder, but not opposing any obstacle to the natural working of 
disease which tends to relieve itself. 

At first I give the patient a dose of oil, which generally relieves 
his giddiness, and direct a mustard foot-bath at night, sometimes 
twice a day, and give him either simple lemonade, a neutral mixture, 
or what is still better the solution of the acetate of ammonia. 



5^5 Goaajaam CLrr^iL 

tf- I V- the knn, dij cii|k s 



f iBeOBDRier; jl 






mild abc 
cakNBKic 



lazaiicef. 



©: 

extiemei' 
of 



The Hi 



TYPHUS AND TYPHOID FEVERS. 557 

dified by the symptoms, and you must study carefully the cases of the 
disease which you see, and bear in mind the pathology and general 
course of the disease, and then you will at least rarely commit any 
important errors. You will find that^ on the whole, the disease 
requires a less stimulating practice than typhus; it is more inflam- 
matory in its primary as well as its secondary lesions. For details, 
I must refer you to the work of Dr. Louis, and to the excellent 
memoir published by Dr. James Jackson, of Boston. 

In your practice you may rarely meet with typhus, but you will 
be sure to see cases of typhoid fever, and you should consider 
the two diseases as distinct, but as allied together more or less 
closely; — each one of them ofl^ering numerous sub-varieties, as 
difierent from each other as a mild case of scarlatina is from a malig- 
nant one. The advantages which 1 enjoyed of carefully studying 
the pathological anatomy, and the symptoms of the two fevers, 
enabled me to place the question of their identity upon more set- 
tled scientific points than had yet been done ; for by reference to the 
writings, both of British and continental physicians, you will find that 
the confusion is but lately dissipated. It is true that, after the obser- 
vations w^hich formed the basis of the paper which I published in 
1837, were collected, but before their publication, Dr. Lombard, of 
Geneva, who was of course familiar with typhoid fever, stated in 
the Dublin Journal that the two diseases were difl^erent ; the same 
remark I remember to have heard Professor Andral make on the 
authority of Dr. Alison ; and it was obvious to many persons that the 
description of Dr. Louis did hot apply to the British typhus, but the 
points of resemblance and of difference were not settled, that is, 
they were not scientifically demonstrated. 

The views which I have given you are gradually receiving the 
sanction of physicians. How far experience may modify them I do 
not know ; but it is probable that it will only add some new facts to 
those which we possess, without impairing their authority. The 
seeming discrepancy of previous statements may be perfectly recon- 
ciled with the facts, as is amply proved by Dr. Valleix, in the 
memoirs which he published on this subject in the Archives de AIS- 
decine, about the beginning of the year 1840. In the last edition 
of his work, Dr. Louis has taken up the same subject, and I am 
gratified to find that, far from retaining any doubts as to the patho- 
logy of these diseases, he fully admits that they are allied, but not 
identical.* 

* The observations of British physicians confirm the views which I gave 
as to the pathology of these fevers. One of the latest writers goes over the 
same grounds as myself, and refers frequently to the memoirs of Dr. Valleix 
without citing the papers which were the subject of his analysis ; nor does he 
ever allude to them, except to give a garbled quotation from Dr. Valleix, — an 
apology, the author says, for citing American instead of British writers upon a 
fever which was especially prevalent in Great Britain. The observations in 
question, however wanting in scientific fairness, confirm the general statements 
as to the symptoms and causes of the continued fevers. 



PATHOLOGICAL INDEX. 



Abscess of the heart, 243 

Ague cake, 185 

Alvine evacuation, peculiarities in 
the, 405 

Amaurosis, 170 

Anasarca with bronchitis, case of, 195 

Anatomy, morbid, connection of, with 
practical medicine, 15 

Aneurism, abdominal, 332 

thoracic, suspected, 61 

Apoplexy, 485, 492 

Aphonia, 166 

Arthritis, 80 

and urticaria, with jaun- 
dice, 120 

Asthma with bronchitis, 68 

Brain, acute softening of, 491 
Bright, disease of, 400 
Bronchitis, 112 

chronic, 24, 68 

mercury in, 370 

with anasarca, case of, 195 

with asthma, 68 

Button-farcy in the human subject, 313 

Cancrum oris, 184 

Carditis, 243 

Cholera, 174 

acetate of lead and opium 

in, 175 
Chorea, 192 
Constitution, gastric, 215 

inflammatory, 216 

Coup de soleil, 348 

Cough, chronic, sarsaparilla and nitric 

acid in, 377 
Cutaneous affections after fever, 395 

Delirium and sleeplessness, 45 

tremens, 499 

Diabetes, 196 

case of, 338 

Diarrhoea, chronic, 144 
Dropsy, case of, 71, 205 

following scarlatina, 399 

with albuminous urine, 399 

Dysentery, 157, 510 
chronic, 144, 516 

Endocarditis, 457 

Enteritis, cured by opium, 140 



Enteritis and peritonitis, case of, 110 
Erysipelas, case of, 59, 153, 264, 391 

epidemic, 269 

Evacuations, alvine, peculiarities in, 

405 
Expectoration in pneumonia, 57 

Farcy, button, in the human sub- 
ject, 313 
Fever, bed sores in, 124 

blisters, &c. in, 203 

blueness of the fingers and toes 

in, 147 

— — maculated, 134, 272 

nervous, 158, 190 

scarlet, 200, 211, 219, 302 

spotted, 135, 273 

supervention of other diseases 

on, 389 

tartar emetic and opium in, 

129, 133, 382 

treatment of, 126, 230, 237, 275, 

278, 286, 306, 322, 341 

typhoid, 272, 551 

typhus, 272, 551 

with cerebral irritation, 379 

with tympanitis, &c., 251 

yellow, 149 

Gangrene and pleuritis, 51 

of the lungs, 529, 537 

Gastric constitution, 215 
Glanders in the human subject, 313 
Gout, 349 

— - — affecting the spinal marrow, 367 
Gouty degeneration of the spinal 
cord, 359 

inflammation, mercury in, 369 

Heart, abscess of the, 242 
Hepatic diseases, 257 
Hepatitis, chronic, 260 
Hoarseness, 168 

Inflammation, constitutional, 349 

gouty, mercury in, 369 

— neuralgia, after fever, 



« 



389 



lung, 371 



scrofulous, of the 



of serous membranes, 447 



Inflammatory constitution, 216 



560 



INDEX 



4^4 



ra,120 



► 



witii arthritis and mtiea- 



^as€d, 399 



lie, 245 

' n Long, 69 

i -ntnatko of tfie. 



jl:"--. :.-t: 

mercary : 
Lang, soli.: 
in, 377 



Measles, 441 

Menmgitis, tabercubns, 465 

acute, 476 

chronic, 484 

Metritis case o^ 404 

Nennofis ^^tem, pathology of th£, 71 
Neozalgm of the &ce, 113 
Xonalgic ingammatio!! after fever. 



(Eaopfaagitis, ease 0^143 

Opiiiin, poiscQiD? by, SageHatkn in, 

284 

Paralysis, 54, S57 

agitans, 194 

Pnapt^ia,84 

Favassaaa in aolidifieafiaii of the 

PeiicardiSis, 242, 457 
Padlaoitis, tabercokKiSi, 455 

fiom liver diaoise, 474 

•- and ^iteiitis, case ci, 110 
ndelist^ case o^ ISO, 392 
Phl^masia ddens, ISO, 391, 402 
mitfaias polmoialk, 521, 5^1, 539 

pefcoaaon in, 378 

sentfaloiis^lKeFentkn 0^373 

Phy^i^igy, impoctance o^ 13 
Pleorisy, 451 

Flemitis and gai^ioie, 51 
FkniD-piieamooia, 161 
Pnenmooia, 57, 543 

complicated with pleuri- 

ti3,160 



Pneamooia, doable, 240 

Poisonina" by opimo, ^g^Iatioa in, 

284 ^ 
Poisons, animal, remarks on, 221 
Prorigo, 248 
Psoriasis diffosed, 155 
Pohnonaiy diseases, leisters in, 310 
Pnlsatidiis of the heart in disease, 66 
Polae, lemarks on the, 142 
PiBtoles of CoQes, 385 

Rbeamatism, acnte, 80, 431 

dnooie, 78 

hydriodate of potass in, 

375 

Seadfttina, 200, 211, 219, 302 

dn^gy tol lowing, 399 

ScEofola, meicofy in, 371 

Seroos membnuies, infiammatinn 

0^447 

38 
and delirium, 45 
Sores, bed, in fever, 124 
^anal cofd, ffooty degeneration of 

the, 359 • " 

goat in the, 367 

S^een, organa^ derangem^it of the, 

262 
Sferanm, molHlity o^ 179 
Syphilid enrption in, 74 

iritis of, 82 

secondary, 73 

Thyroid gland, affection of the, 150 
Tic doalooreux, simulation of, 118 
Tabercalar meningitis, 465, 550 
Tympanitis with fever, 251 
Typhoid fever. 272, 551 
Typhas, 272, 551 

spotted or ernptive, 381 

tartar emetic and opiam in, 

382 

Urine, albaminous, 400 

retention of, 232 

Urticaria, 122 

and arthritis with jamidice, 120 

Utero^ infianuxmtioQ of tbe, 404 

Velpeaa's treatment of sore throat, 169 
Yesides of Colles, 395, 398 
Voices loss ot^ 166 



\^ Philadelphia, September, 1841.] 
THE 



SELECT MEDICAL LIBEARY 

(.YEJV SERIES) 

AND 

MnUttin of ^tUtnl Btitntt. 



EDITED BY 



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13 



STANDARD WORKS 

PUBLISHED IX 
From NOVEMBER, 1836, to OCTOBER, 1837. 



1. LECTURES on the MORBID ANA- ■. 
TOMY. NATURE, and TREAT- i 
MENT of ACUTE and CHRONIC 
DISEASES. By the late Johv Arm- 
STROG, M.D.; Author of •' Practical i 
Illustrations of Typhous and Scarlet ; 
Fever," &c. Edited by Joseph Rrx, , 
Member of the Royal College of Sur- 
geons. ' 
The British and Foreign Medical Review j 
says of this work : | 
" We admire, in almost every pa^ e, the pre- f 
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general instructions arising out of the lecturers '. 
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some of the heroic remedies, as mercur?-. arsenic, I 
and colchicum. attest his powers of observation j 
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•2. OBSERVATIONS on "the PRINCI- ' 
PAL MEDICAL INSTITUTIONS 
and PRACTICE of FRANCE, ITA- 
LY and GERMANY: with Notices of 
the Universities, and Cases from Hos- I 
pital Practice : With an Appendix on j 
ANIMAL MAGNETISM and HO- } 
MGEOPATHY. By Edwin Lze, 
Member of the Royal College of Sur- 
. geons. &c. 
• Mr. Lee has judiciously selected some clini- 
cal cases, illustrating the practice pursued at the 
different hospitals, and he has wound up the vo- 
lume with an amusing account of animal mag- 
netism and homcBopath}' — those precious effu- 
sions of German idealty. for which we refer to 
the work itself — .Medico- CAirurg. Ret. 

3. A THERAPEUTIC ARRANGE- 
MENT and SYLLABUS of MATE- 
RLA .MEDIC a. Bv James Johnstoxe, 
M.D., Fellow of the College of Physi- 
cians, and Physician to the General 
Hospital. Eirmmgham. 

• This book cannot but be particularly useful 
to those who intend to lecture or write upon the 
Materia Medicar as well as to the students for 
whose particular use it is prepared."— .Brjf. and 
For. Med. Rev. 

4. A TREATISE ON TETANUS, being 
the ESSAY for which the Jacksosia.v 
Prize for the year ]S34, was awarded, 

14 



by the Royal College of Surgeons in 
London. By Thcmas Blizard Ccrl- 
iN'G., Assistant Surgeon to the London 
Hospital, d:c. 

" This book should be in the library- of every 
surgeon and physician. It is a valuable work of 
reference. It does not pretend to originality, for 
originality on such a subject was not wanted. 
But a compendium of facts icas wanted, and such 
a compendium is this volume. We cannot part 
from Mr. Curling without thanking him for the 
information we have received in' reading his 
work, and for the matter it has enabled us to 
offer to our readers."'— .Ve<f!co-C/iir. Rer. 

5. PRACTICAL OBSERVATIONS on 

DISEASES of the HEART. LUNGS, 
STOMACH. LIVER. &c., OCCA- 
SIONED BY SPINAL IRRITA- 
TION: AND ON THE NERVOUS 
SYSTEM IN GENERAL, AS A 
SOURCE OF ORGANIC DISEASE. 
Illustrated by Cases. By John Marshall, 
M.D. 

6. A TREATISE ON INSANITY AND 
OTHER DISEASES AFFECTING 
THE MIND. By James Cowles Prich- 
ard, M.D. F.R.S. Corresponding Mem- 
ber of the Institute of France, &c. 

'•The author is entitled to great respect for his 
opinions, not only because he is well known as 
a man of extensive erudition, but also on ac- 
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subject on which he writes. The work, we may 
safelv sav. is the best, as well as the latest, on 
mental deransement, in the English language." 
—Medico- Cki r. Rex . 

7. BOUILLAUD ON ACUTE ARTI- 
CULAR RHEUMATISM IN GEN- 
ERAL. Translated from the French, for 
this Library, by James Kitchex, M.D., 
Philada. 

8. A PRACTICAL TREATISE ON 
I THE PRINCIPAL DISEASES OF 

THE LUNGS. Considered zspe- 

I CIALLY IX RELATION TO THE PARTICU- 

I LAR Tissues affected, illustrating 

THE different KINDS OF CoUGH. By 

G. Hume Weatheihead, M.D., 3Iember 

of the Royal College of Physicians, 

Lecturer on the Principles and Practice 

of Medicine, and on Materia Medica 

and Therapeutics, &c. cfcc. 

EPIDEMICS OF THE MIDDLE AGES. 

From the German of I. F. C. Hecker 

M.D., &c. &c. Translated by R. G. 

Babington, M.D. F.R.S. — 



Articles in the Library and Eclectic Journal of Medicine, 



9. No. I.— THE BLACK DEATH IN 

THE 14th CENTURY. 

" Hecker's account of the ' Black Death,' which 
ravaged so harge a portion of the globe in the 
fourteenth century, may be mentioned as a work 
worthy of our notice, both as containing many 
interestingdetails of this tremendous pestilence, 
and as exhibiting a curious specimen of medical 
hypothesis." — Cyclopedia of Practical Medicine — 
Historij of Medicine by Dr. Bostock. 

10. No. II.— THE DANCING MANIA. 

" Medical History has long been in need of the 
chapter which this book supplies ; and the defi- 
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season. On the whole, this volume ought to be 
popular; to the profession it must prove highly 
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touching an important subject which had almost 
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think that to Dr. Babington especial thanks are 
due for having naturalised so interesting a pro- 
duction. The style of the translation, we may 
add, is free from foreign idioms : it reads like an 
English original."— Zowrf. Med. Oaz. 

11. LECTURES on Subjects connected 
with CLINICAL MEDICINE. By 
P. M. Latham, M.D. Fellow of the 
Royal College of Physicians, and Phy- 
sician to St. Bartholomew's Hospital. 



" We strongly recommend them [Latham's 
Lectures] to our readers; particularly to pupils 
attending the practice of our hospitals." — Loud 
Med. Oaz. 

12. ELEMENTS OF SURGERY, in 
Three Parts By Robert Liston, Fel- 
low of the Royal College of Surgeons 
in London and Edinburgh, Surgeon to 
the Royal Infirmary, Senior Surgeon 
to the Royal Dispensatory for the City 
and County of Edinburgh, Professor of 
Surgery in the London University, &c. 
&c. 
" In the present work, an endeavour has been 
made, in the first place, to lay down, correctly 
and concisely, the general principles which ought 
to guide the Practitioner in the management of 
constitutional disturbance, however occasioned. 
" The observations introduced to illustrate the 
doctrines inculcated, are given as briefly as is 
consistent with an accurate detail of symptoms 
and results. The descriptions of particular dis- 
eases have been sketched and finished from na- 
ture ; and, it is hoped, with such fidelity, that 
their resemblance will be readily recognized. 

" Such modes of operating are described, as 
have been repeatedly and successfully performed 
by the Author." 



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In the eclectic JOURNAL OF MEDICINE, Vol. I., or First Year, 

HAVE BEEN PUBLISHED, 

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articles on Physiology, Pathology, Therapeutics, Midwifery, Surgery, and 
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PROM NOVEMBER, 1837, TO OCTOBER, 1838, 



HAVE BEEJV PUBLISHED, 



1. A PR.ACTICAL TREATISE ON 
DISEASES OF THE SKIN, ar- 
ranged with a view to their Constitu- 
tional Causes and Local Character, &c. 
By SAMUEL PLUMBE, late Senior 
Surgeon to the Royal Metropolitan In- 
firmary for Children, &,c. Illustrated 
with Splendid Coloured Copperplate 
and Lithographic Engravings. 

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on Cutaneous Diseases, is, in this new edition, 
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Breschet, and Vauzeme. The illustrations of 
cutaneous disease are happily exhibited, and are 
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pensable to the medical man."— jinnals of Medi- 
cine, January, 1837. 

Plumbe on Diseases of the Skin. — " This excel- 
lent Treatise upon an order of diseases, the pa- 



thology of which is, in general, as obscure as the 
treatment is empirical, has just been republished 
in the Select Medical Library, edited by Dr. John 
Bell, of this city. We hail with pleasure the 
appearance of any new work calculated to elu- 
cidate the intricate and ill-understood subject of 
skin-diseases. The late Dr. Mackintosh, in his 
Practice of Physic, recommends it as the 'best 
pathological and practical treatise on this class 
of diseases, which is to be found in any lan- 
guage.'" — Phil. Med. Exam., Jan. 17, 1838. 

"This work is one of the most excellent on 
the Diseases of the Skin, in the English Ian- 
guage." — West. Jour, of Med. and Phys. Sciences, 
Jan. 1838. 

2. THE MEDICAL PROPERTIES of 
the NATURAL ORDER RANUN- 
CULACEiE, &c. &c. By A, Turn- 
bull, M.D. 

3. THE GUMS ; with late Discoveries on 
their Structure, Growth, Connections, 
Diseases, and Sympathies. By George 

15 



Catalogue of Works published m the Select Medical Library, 



\y . : T I ' ' r ber of the London £oja) 
C f-T : P -vsicians. 
A PRACTICAL TREATISE ON 



aeqaainted trith tbe best mode of ai^riBg ap- 
faratas. in cases of wounds, fractures, disloea- 
tions> &:c. Tbe plates and descriptions of Ibis 
work, sive this important information." — Ba.: 

MIDWIFERY; Containing the Re- C4^««-~ 

suits of Sixteen Thousand Six Hon- ; 7. QX THE INFLUENCE OF PHY- 



dred and Fiftj-fonr Births, occorriog in ' 
the Dublin Ljing-in HospitaL By Ro- 
bert CoLLiKs, M.D.; Late Master of 
the InstitDtion. 



SICAL AGENTS 0.\ LIFE. By 

W. F. Edwards. M.D., F.R.S., etc. 

Translated frpm the French, br Drs. 

Hodgkin and FL=her, To which are 
-- Sereral reprints of ^eat -ralne haTe already \ added, some Observations on Elxctri- 
appeared in the I-ibraiy— among otheis. Prich- [ ^itt, aod Notes to the work, 
ard on Insanitv, Corling on Tetanos Latbam's f _, j •, . - - 

CiiaicalLectores, &:c. Tbe Xomber for tbe pre- "This is a work of standard anthonty m 
sent month commences CoUins's Treatise on i Medicine: and, in a pbrsiological point of view, 
aiidwifery. a work rich in statistical details.'^— »* pre-«nunently tbe most valuable publication 
Pkil. Med. Exam^ Jam. 17. ie38. »*" ^e present century ; tbe experimental inres- 

^.mu . »L T»» t >rv T> ..- £. 1 » t^ ligation instituted by the autbcr. havin£ done 

%/J^.^^r*^°** 3^umberofDr Belts fcelect | ^=^ ^^^^^ ^^^ manr problems hitherto 
M^cal I^rary contains the concln|iou of A j ^ partiallT nn^erstdod. Tl^ «ort was orisi- 
P act.cal Treause on Jlidwifery. by Eobert Col- oauf^esented in parls to the RoTal Acadeiv 
«''' ; 'i^ '^^^"fJl *^ the Dublin Lying-in ^^ ^^^^ ^j- p^^^j so highlT did Ihev esti- 
S^^'^^^'h^^^ '^'V"'^ "^iJ^^- ^^^'^ **^ ^"^^ •nate the labours of the author, ind so Mly ar 
pyed the nomeneal meihi^oi M. Lows; and j ^^ ^^^ ^ ^;^ ,^,^^ rendered i: 

hv accurate taW«s of classification, enables his [ ^^„^ ,^ ,^, humanity, that they awards J 
Traders to perreiTe, at a glance, Uie conse- ^j^ ,„^,„^^ ^ foreigner, the i^ize founded for 
.Fjences r.f the diveisifi^ conditions in which ^^ p^oml^ion of es^rimental physiology, 
^e saw his patients. Avast amount of mforma- ^ - *^ ^ -^ "^-^ 

tion is thus obtained, which is inralaable to 
those who duly appreciate precision in the ex- 
amination of cases.'^ — Bali. Ckraa. 



a practical treatise on 
th; 



His researches relate to what are 
oated the Physical Agents, viz: Temperature, 
as modified in degree and duration; Electricity ; 
Air. as regards quantity, motion ch- rest, density 
or rarity ; Water, as a liquid and in a state of 
VT A "VAr^r virvT* Avn m4' f vapour; and Usht; and his object is to show 
rA5r« ;Vp T^ufi norV^ c iT i the effects produced on the human system by 

LAv-Lo KJt V. rllL.lJr4JL_\. Dj iiiCH- ; these agents which surround and are incessantly 
AKD T. EvA5505, M.D., Proie-sor of : eiercislng an influence upon us. 

I *■ It is hardly nece^ry for us to say, that the 
design has been executed in a masterly man- 
ner, and that the profession is under deep"obliga- 
tioEs to Dr. Edwards, for so satisfactorily per- 
forming his task, and furnishing it with such a 
body of facts, anni sudi a vast number of experi- 
ments, in illustration and confirmation of his 
views.'' — PnoT. Jfrur. 



Aledicine. — aud Hexrt Macssell, 
SLD, Professor of MidwLlerv, — in the 
College cf Surgeons in Ireland. 
'- The autlMtrs of the work before us, have had 
iSie advantage of investigating the subject of 
infantile Diseases, conjointly in a public insti- 
tution — an advantage n hieh no private medical 
man. however extensive his practice, could pro- 
KoKty have. The observations being madecon- 
:.::j too, o&r a greater guarantee of correct- 
-^ r.nd authenticity, than if they emanated 
I -.a. a single source, however res|.ec.table. From 
their acquaintance, also, nith foreign wcrks, 
tbey have been able to bring up the Anatomy, 
Piiysiology. Pathology, and even Therapeutics. 
to a far higher level than is to be found in any 
previous work in the English language. [ 

" The second chapter embraces the Manage- 1 
ment and Ph3rsicai Education of Children, litis l 1. 
chapter ought to be printed in gold letters, and f 
hung up in the nursery of every family. It I 
would save many lives, and prevent much suf- I 
faring." — MaRca-Giirurg. Hit. [ 

"'■ "We know of no work to which, on the ^-. 
whole, so little can be objected in matter or 11 
manner. It is an elegant and practical com- j. 



8. 



^9. 



Prof. HORNER'S NECROLO- 

GICAL NOTICE OF DR. P. S. 

PHYSICK; Delivered before the 

American Philos. Society, May 4. 

1838. 

ESSAYS ON PHYSIOLOGY 

AND HYGIENE; viz: 

REID'S EXPERIMENTAL IN- 
VESTIGATION i-VTo THE FUNC- 
TIONS OF THE EIGHTH PAIR 
OF NERVES. 

EHRENBERG'S MICROSCO- 
PIC \L OBSERVATIONS on the 
BRAIN AND NERVES (with 

KCMEEOrS EXGSATiyGS\ 



pendinm of Infantile Diseases: a safe guide in 
the Management of Children ; and completely f 
fhlfils^he parpf^es proposed."^ — Britisk ,3mMais | 

GLIDE UN DRLa^IiSG. and in the f 
Methodic APPLICATION of BAND- [ 
AGES. Ilinstrated by 05x hcsdred '' 



VOUS ACTIVITY; by Professor 
Stbosieter. Hanover. 



E.VGRAV15GS. By ThCMAS CcTLEK.JLD. 

late Staff Surgeon m the Belgian Army. 
'■ Ci-TLEK on Bandages, with one hundred il- 
Sdslrative Engra^ngsTwiU be invaluable to the 
great majority of the profe^ion. threnghout this 
country. Bat few have had the opportunity, 
which a large hospital only ^fiords, of becoming ( 

16 



IV. VEGETABLE PHYSIOLOGY. 

V. EXPERIMENTS ON THE 
BRAIN. SPLNAL MARROW, 
AJfD NERVES. By Prof. Mater, 
of Bonn (vtith woodccts). 



and of Articles in the Eclectic Journal of Medicine. 



VI. PUBLIC HYGIENE. 

VII. PROGRESS OF THE ANATO- 
. MY AND PHYSIOLOGY of the 

NERVOUS SYSTEM, during 
1836, By Professor Muller. 

VIII. VITAL STATISTICS. 

10. CURIOSITIES OF MEDICAL 
EXPERIENCE. By J. G. Mil- 
LiNGEN, Surgeon to the Forces, 
Member of the Medical Society of 
the Ancient Faculty of Paris, etc., 
etc. 

" P'uriosities of Medical Experieiice, By J. G- 
MiLLiNGEN, Surgeon to the Forces, etc. The 
Author or Compiler derived the idea which 
prompted him to write this work from Disraeli's 
'Curiosities of Litt^rature ;' and, in our view, 
he has made a hook equally curious in its way 
with that one. The heads of his chapters are 
numerous and varied; and all his subjects are 
treated in an agreeable and comprehensible 



style to the general reader. The drift of the 
Author, too, is decidedly useful. We shall en- 
deavour to give some extracts from this work." 

— JVai. Gaz. 

11. MEDICAL CLINIC; or, Re- 
ports of Medical Cases: By G. 
Andral, Professor of the Faculty 
of Medicine of Paris, etc. Con- 
densed and Translated, with Obser- 
vations extracted from the Writings 
of the most distinguished Medical 
Authors: By D. Spillan, M.D., 
etc., etc. ; containing Diseases of the 
EncepJialon^ &c., with Extracts from' 
Ollivier's Work on Diseas'is of the 
Spinal Cord and its Membranes. 

12. AN ESSAY ON DEW, and several 
Appearances connected with it; by 
William Charles Wells, M.D 
F.R.S., etc. 



JOUKNAIi DEPARTMENT. 
In the eclectic JOURNAL OF MEDICINE, Vol. IL, or Second Year, 

HAVE BEEN PUBLISHED, 

Original Articles on Animal Magnetism, Laryngeal Phthisis, Elephantiasis, 
the Use and Abuse of the Pessary, Dislocation of the Elbow Joint, Lithotripsy, 
Pneumonia Typhoides, Excision of the Neck of the Uterus, the Plague of 
Athens, translated from the Greek of Thucydides; the Application of Turpen- 
tine in Tetanus, Medical Schools and Professorships, the Use of the Balsam of 
Copaiba in Diseases of the Mucous Membrane of the Intestinal Canal, on an 
Improved Auriscope — with engraving; the Solar Speculum — with engraving, 
&c. ; Digests and Reviews of several new Works. Numerous Articles on Phy- 
siology, Chemistry, Pathology, Therapeutics, Midwifery, Surgery, and Hygiene, 
with an Index and Title-paofe, — forming a handsome volume of nearj^we hundred 
closely printed pages; which, with the LIB R ARY , amounts to near THREE 
THOUSAND pages for TEN DOLLARS; containing as much matter, (and 
that selected from the best authors,) as in ordinary medical works would occupy 
five thousand pages, or twelve volumes. 



Ill tlie Ijiferary, Third' Tear, 

COMMENCING NOVEMBER, 1838, AND ENDING OCTOBER, 1839, 



HAVE BEEN PUBLISHED, 



LECTURES ON THE PHYSIO- 
LOGY AND DISEASES OF THE 
CHEST; induding the Principles of 
Physical and General Diagnosis. De- 
hvered during the Spring Sessions of 
1836 and 1837, at the Anatomical 
School, Kinnerton Street, near St. 
George's Hospital. By Charles J. B. 
Williams, M.D., F.R.S. Professor of 



the Principles and Practice of Medicine 
in University College, London. With 
Engravings. 

ESSAY UPON THE QUESTION, 
IS MEDICAL SCIENCE FAVOR- 
ABLE TO SCEPTICISM? By 
James W. Dale, M.D., of Newcastle, 
Delaware, 

17 



Catalogue of Works published in the Select Medical Library, 



3. LECTURES ON THE PRINCI- 
PLES OF SURGERY. By John 
Hunter, F.R.S. With Notes by 
James F. Palmer, Senior Surgeon to 
the St. George's and St. James's Dispeu- 
saries, &c. &c. With Plates. 

"We have perused these lectures with no or- 
dinary feelings of satisfaction. They embody an 
immense amount of important facts, directed 
with no common skill to the illustration and 
improvement of medical science generally, and 
of the surgical department in particular. Indeed 
we have no hesitation in saying, that, whatever 
be the position of the reader in the profession, he 
will not relinquish the perusal of these lectures 
without the consciousness of having usefully 
employed the time which he may havebestowed 
upon them. For they constitute, in the fullest 
senseof the term,a philosophical disquisition on 
the science of Surgery; and hence, embracing 
the great principles on which the whole art of 
healing rests, their interest will be felt by all 
who regard Medicine as a true branch of science, 
and who delight to witness the gradual develop- 
ment of principles in the right interpretation of 
the phenomena of nature." 

" We cannot bring our notice of the present 
volume to a close without offering our testimony 
to the admirable manner in which the editor and 
annotator has fulfilled his part of the underta- 
king. The advancements and improvements j 
that have been effected, up to our own day, not j 
only in practical surgery, but in all the collate- i 
ral departments, are constantly brought before 
the reader's attention in clear and concise 
terms:'— Brit. 8^ For. Med. Rev. 

" The surgical lectures alone were sufficient 
to fix us long in our chair, and our pains were 
amply compensated by the perusal of the very 
words in which Hunter had instructed his class." 

" The rescuing of these lectures from that ob- 
livion which they must needs have fallen into in 
private hands, alone constitutes the editor of 
Hunter's works a benefactor to the student and 
the scholar." — Medical Gazette. 

4. ON DENGUE; ITS HISTORY, PA- 
THOLOGY, AND TREATMENT. 
By S. Henry Dickson, M.D., Pro- 
fessor of the Institutes and Practice of 
Medicine in the Medical College of S.C. 

5. OUTLINES OF GENERAL PA- 
THOLOGY. By George Frecele- 
TON, M.D., Fellow of the Royal College 
of Physicians. 

6. URINARY DISEASES and their 
TREATMENT. By Robert Wil- 
lis, M.D.. Physician to the Royal In- 
firmary for Children, &c. &c. 

"We do not know that a more competent au- 
thor than Dr. Willis could have been found to 
undertake the task ; possessing, as it is evident 
from his work that lie does possess, an accurate 
acquaintance with the subject in all its details, 
considerable personal experience in the diseases 
of which he treats, capacity for lucid arrange- 
ment, and a style of communication commenda- 
ble in every respect." 

" Our notice of Dr. Willis's work most here 
terminate. It is one which we have read and 
trust again to read with profit. The history of 
discovery is successfully given; cases curious and 
important; illustrative of the various subjects 
have been selected from many new sources, as 
well as detailed from the author's own experi- 

18 



ence, chemical analyses, not too elaborate, have 
been afforded, which will be'most convenient to 
those who wish to investigate the qualities of 
the urine in disease; the importance of attend- 
ing to this secretion in order to a proper under- 
standing ol disease is strongly insisted upon ; in 
short, a" book has been composed, which was 
much required, and which w^ecan conscientious. 
Iv and confidentlv recommend as likely to be 
useful to all classes of practitioners.— £rit. <^ 
For. Med. Rev. 

7. LECTURES on BLOOD-LETTING. 
By Henry Clutterbuck, M.D. 

8. THE LIFE OF JOHN HUNTER, 
F.R.S. By Drewry Ottley. 

"In the summing up of Mr. Hunter's character, 
Mr. Ottlev exhibits equal judgment and can- 
dour."~£Vjf. <^- For. Med. Rev. 

9. HUNTER'S TREATISE ON THE 
VENEREAL DISEASE. With Notes 
by Dr. Babington. Wilh Plates. 

"Under the hands of Mr. Babington, who has 
performed his task as editor in a very exempla- 
ry manner, the work has assumed quite a new 
value, and may now be as advantageously 
placed in the library of the student as in that of 
the experienced surgeon.— JSrfj. 8c For. Med. Rev. 

" The notes, in illustration of the text, con- 
tain a summary of our present knowledge on 
the subject ; the manner in w^hich these notes 
areconstructed is at once clever and perspicuous; 
and the modes of treatment prescribed, spring 
from a richt apprehension of the disease. We 
would recommend to the reader the note on the 
primary venereal sore ; the note itself is an es- 
say in everv word of which we fully concur."— 
Med. Gazette. 

10. A TREATISE ON THE TEETH. 

By John Hunter. With Notes by 
Thomas Bell, F.R.S. With Plates. 
" The treatise on the teeth is edited by Mr. 
Bell, a gentleman accomplished in his art. Mr. 
Bell has studied his subject with the greatest mi- 
nuteness and care; and in appropriate notes at 
the first of the page corrects the author with 
the air of a gentleman, and the accuracy of a 
man of science. The matter contained in these 
short notes forms an ample scholum to the text ; 
and without aiming at the slightest display of 
learning, they at the same time exhibit a ready 
knowledge on every point, and an extensive in- 
formation both of comparative anatomy and 
pathology.— Jkferf. Gazette. 

11. MEDICAL AND TOPOGRAPHI- 
CAL OBSERVATIONS upon the 
MEDITERRANEAN and upon POR- 
TUGAL. SPAIN, AND OTHER 
COUNTRIES. By G. R. B. Hor- 
ner, M.D., Surgeon U. S. Navy, and 
Honorary Member of the Philadelphia 
Medical Society. With Engravings. 

" An uncommonly interesting book is present- 
ed to those who have any disposition to know 
the things medical in Portugal, Spain, and 
other countries," and ' will doubtless be read, 
also, with marked satisfaction by all who have 
a taste for travels."— £osi. Med. and Surg. Jour. 

12. LECTURES ON THE BLOOD, 

AND ON THE CHANGES -^VHICH IT 

UNDERGOES DURING DISEASE. By 
F. Magendie, M.D. 



and of Articles in the Eclectic Journal of Medicine. 



JOURNAL DEPARTMENT. 

In the eclectic JOURNAL OF MEDICINE, Vols. III., IV., or 
Third and Fourth Years, 1838-40, have been published. 

Original Reviews and Bibliographical Notices, viz., of Hosack's Lectures 
on the Theory and Practice of Physic, Walker on Intermarriage, the Works of John 
Hunter, Introductory Lectures, Granville on Counter-Irritation, Gallup's Outlines 
of the Institutes of Medicine, Bouvier on Club Foot, Harris's Dental Surgery, 
Viinont on Human and Comparative Physiology, &c., &c.: also, Selected Reviews 
of Lonsdale and Burke on Fractures, Foissac on the Influence of Climate, Le- 
canu and Denis on the Chemistry of the Blood, Gondret &c. on Counter-Irrita- 
tion, &c., &c.: Papers on Club Foot, Yellow Fever, Pathology of the Ovaria, 
Extirpation of the Parotid Gland, Endermic Medicine, Simple Ulceration of the 
Stomach, Artificial Digestion, Diseases of the Kidneys, Diseases of the Spine, 
Irritable Bladder, Fibres of the Spinal Marrow, Experiments on theBlood, Galvanic 
Experiments on a Dead Body, &c., &c., and numerous other articles on Thera- 
peutics, Pathology, Surgery, and Midwifery. 

4:** Each Volume of the JOURNAL contains above 500 pages of closely 
printed matter. 



In the liibrary. Fourth Yearg 

COMMENCING NOVEMBER 1839, AND ENDING OCTOBER 1840, 

HAVE BEE J^ PUBLISHED, 



1. MEDICAL NOTES AND REFLEC- 
TIONS. By Henry Holland, M.D., 
F.R.S., Fellow of the Royal College of 
Physicians, and Physician Extraordi- 
nary to the Q,ueen. 

2. CLINICAL REMARKS ON SOME 
CASES OF LIVER ABSCESS PRE- 
SENTING EXTERNALLY. By 

John G. Malcolmson,M.D. Surgeon 
Hon. E. I. C. Service, Fellow of the 
Royal Asiatic Society, and the Geolo- 
gical Society, London. 

3. HISTORICAL NOTICES ON THE 
OCCURRENCE OF INFLAMMA- 
TORY AFFECTIONS OF THE IN- 
TERNAL ORGANS AFTER EX- 
TERNAL INJURIES AND SUR- 
GICAL OPERATIONS. By Wil- 
liam Thompson, M.D., &c. &c. 

4. A EXPERIMENTAL INVESTI- 
GATION INTO THE FUNCTIONS 
OF THE EIGHTH PAIR OF 
NERVES- By John Reid, M.D., &c. 

5. TREATISE ON THE BLOOD, IN- 
FLAMMATION, AND GUN-SHOT 
WOUNDS. ByJohn Hunter, F.R.S. 
With Notes, by James F. Palmer, 
Senior Surgeon to the St. George's 
and St. James's Dispensary, &c., &c. 



6. A PRACTICAL TREATISE ON 
VENEREAL DISORDERS, AND 
MORE ESPECIALLY ON THE 
HISTORY AND TREATMENT OF 
CHANCRE. By Philippe Ricord, 
M.D., Surgeon to the Venereal Hos- 
pital at Paris. 

7. A TREATISE ON INFLAMxMA- 
TION. By James Macartney, F.R.S. , 
F.L.S., &c., Ac. Member of the Royal 
College, of Surgeons, London, &c., &c. 

8. AMUSSAT'S LECTURES ON 
THE RETENTION OF URINE, 
CAUSED BY STRICTURES OF 
THE URETHRA, and on the Diseases 
of the Prostate, translated from the 
French by James P. Jervey, M.D. 

9. OBSERVATIONS ON CERTAIN 
PARTS OF THE ANIMAL GECON- 
OMY, Inclusive of several papers from 
the Philosophical Transactions, &c. By 
John Hunter, F.R.S., &c., &c. With 
Notes by Richard Owen, F.R.S. 

" One distinctive feature of the present edition 
of Hunter's works has been already mentioned, 
viz: in the addition of illustrative notes, which 
are not thrown in at hazard, but are written by 
men who are already eminent for their skill and 
attainments on the particular subjects which 
they have thus illustrated. By this means, whilst 
we have the views entire of John Hunter in the 

19 



Catalogue of Books, Terms of Subscription, etc. 



text, we are enabled by reference to the accom- | 
panying notes, to see wherein the author is borne 
out by the positive knowledge of the present day, 
or to what extent his views require modification 
anrt correction. The names of the gentlemen 
who have in this manner assisted Mr. Palmer, 
are guarantees of the successful performance of 
their task." 

10. HINTS ON THE MEDICAL EX- 
AMINATION OF RECRUITS FOR 
THE ARMY; aiad ou the Discharge j 
of Soldiers from the Service on Sur- 
geon's Certificate : Adopted to the Ser- 
vice of the United States. By Thomas 
Hexdersox, M. D.. Assistant Surgeon 
U. S. Army, &c., &c. 

AN ESSAY ON HYSTERIA; being 
ananalysisof its irregnlarandaggravated ' 
forms; including Hysterical Henjorrhase 



11 



and Hysterical Ischuria. "With nnmer- 
ous Illustrations and Curious Cases. 
By Thomas Latcock, House Surgeon 
to the York County Hospital. 

12. A TREATISE ON THE CAUSES 
AND CONSEQUENCES OF HABI- 
TUAL CONSTIPATON. By Johx 
BuR>-E, M.D., Fellow of the Royal Col- 
lege of Physicians, Physician to the 
Westminster Hospital, &c. &c. 

"For some interesticc cases illustrative of this 
work, the author is indetted to Dr. Williams, Dr. 
Stroud, Dr. Callaway. 3Ir. ^lorsran, iMr. Taimton. 
Dr. Knots, Sir Astlev Cooper, Sir Benjamin Brodie . 
Mr. Tupper, ]Mr. "Bailer, Dr. Paris, 3Ir. Dendy, 
Dr. Hen. L . Thomson," Sic— Preface. 

13. A TREATISE ON MENTAL DIS- 
EASES. By M. EsQuiROL. 



O^The Works published :n either year, as enumerated above, with the 
Eclectic JouRXAL, nan be obtained bound in 6 vols, for -$13; or, the whole 
Series, 24 volumes, bound in uniform style, for 852. 

TERMS OF SUBSCRIPTION 

TO 

THE SELECT MEDICAL LIBRARIT, 

Published QuARXEaLT, 
IN JANUARY, APRIL, JULY, AND OCTOBER. 

Each Number of the Library will consist of one or more approved works on 
some branch of Medicine, including, of couise. Surgery and Obstetrics. 

Every work in the Library will be completed in the number in which it is 
begun, unless the subject naturally admits of division; ?.nd hence the size of the 
numbers will vary. It will be done up in a strong paper cover, and each work 
labelled on the back; thus obviating the immediate necessity of binding. 

Subscribers will receive fourteen hundred pages of closely printed matter of 
Library in the year. , 

To each number of the Library will be appended a Bulletin of Medical Science 

FIVE DOLLARS per annum, in advance; and in no single instance, out of 
the chief cities, will this rule be departed from. 

Subscribers who wish to receive the Library direct from us must remit the amount 
of their subscription ,• as none of our agents are authorized to receive money on our 
account ; nor will we hold ourselves responsible for any defalcations on their part. 

BARRINGTON & HASWELL, 
Publishers, 293 Market Street, Philadelphia. 



In the Libra ry 

HAVE BEE.X PL 
In the January Number, 
A PRACTICAL DICTIONARY 2 
OF MATERIA MEDICA, includ- 
ing the Composition, Preparation and i 
Uses of Medicines ; and a large num- 
ber of Extemporaneous Formulae : ■ 
together with important Toxicological 
Observations; on the Basis of Brande'' s \ 
Dictionary of Materia Medica and 3, 
Practical Pharmacy ; by Johx Bell, 
M.D., Lecturer on .Materia Medica i 
and Therapeutics, &c. &c. ; and, i 
20 



, Fifth Tear, 

BLISHED, 

In the Jpril Number, 
, SCHILL'S OCTLINES OF 
PATHOLOGICAL SEMEIOLO- 
GY, Translated by D. Spillan, 
M.D., &c. ; andARET.EUS ON 
THE CAUSES AND SIGNS OF 
ACUTE DISEASE. 

In the July Number, 
MILLINGEX'S APHORISMS 
ON INSANITY ; and DISEASES 
OF THE WOMB, by Waller, 
LiSFRANC, Ingleby. and Lee. 



LIST OF WORKS 



SUPPLIED, BT MAIL, AS 



SELECT MEDICAL LIBRARY 
Extras. 



Subscribers to the Library and Bulletin^ and the Medical Faculty in gener al 
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To the name of each work is slated its number of sheets and the selling price ; 
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BARRINGTON & HASWELL. 



N.B. Those works comprised within brackets are bound in one volume, and 
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LEE'S OBSERVATIONS on the PRINCIPAL MEDICAL INSTI-^ f 
TUTIONS and PRACTICE of FRANCE, ITALY, and GER- ' i I 
MANY, ifec, with an Appendix on ANIMAL MAGNETISM and ! £ .' , _ 
HOMCEOPATHY. {-^S^^^^ 

JOHNSTONE'S SYLLABUS of MATERIA MEDICA. j ^ 

LATHAM'S LECTURES ON CUNICAL MEDICINE. j 



A TREATISE ON TETANUS, by Thomas B. Curling. Iff 

BOUILLAUD ON ACUTE ARTICULAR RHEUMATISM in >^ < 80 
general. TransZofed/rom fAeFrenc/i, by Jamse Kitchen,. M.D. j "" 



PRACTICAL OBSERVATIONS on DISEASES of the HEART^ . f 
LUNGS, STOMACH, LIVER, &c. By John Marshall, M.D., &c. | f | 

WEATHERHEAD on DISEASES of the LUNGS ; considered especi- >^ < $ 80 
ally in relation to the particular Tissue affected illuslraitng the different | "= | 
kinds of Cough, }^ V 

PRICHARD on INSANITY and other DISEASES affecting the MIND. 
14 sheets. . , , .. , . 1 25 

t xxi 



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EPIDEMICS of the MIDDLE AGES, viz. The Black Death and Dancing 
Mania; translated from the German of Hecker. bv Dr. Babington, F.R-S. 
7 sheets. . . . . ' . . . 60 



The ECLECTIC JOLTINAL of MEDICINE, bv John Bell, M.D., from 
November, lc36, to October, 1837. 19 sheets. ' . . . 2 00 



PLUMBE ou DISEASES of the SKIN ; with splendid coloured Engrarings. 

]7 sheets. . . . . . . . 2 25 



TT7RNBULLS TREATISE on the 3IED1CAL PROPERTIES of the ) . f 
Natnral order RAM'XCULACEJE. &e. &c. | f | 

THE GEMS ; their structure. Diseases, Sympathies, &c. Bv George )>J { So 
Waite. ' i =' I 

An ESSAY on DEW, &c. By W. C. Wells. F.RS. j- I 



COLLLNS'S PRACTICAL TREATISE on MIDWIFERY. 11 sheets, . 125 



EVANSON and 31 A U.XS ELL on the MANAGEMENT and DISEASES 
of CHILDREN. 13 sheets, . . . . .150 



The SURGEON'S PRACTICAL GUIDE in DRESSING, and in the 
Methodic APPLICATION of BANDAGES. lUustrated hy 100 Engravings. 
Bj Thomas Cutler, M.D., &c. 4 sheets. . . . .0 60 



EDWARDS on the INFLUENCE of PHYSICAL AGENTS on LIFE: 
with observations on ELECTRICITY, »fcc. lu sheets. . . .100 



HORNEPJS NECROLOGICAL NOTICE OF DR. P. S. PHYSICK.^ . f 
IS MEDICAL SCIENCE FAVOURABLE TO SCEPTICISM ? 1 | | 

Bv Dr. Dale, of Newcastle. Delrriware. }^ { ^ ^ 

on' DENGUE; its HISTORY, PATHOLOGY, and TREATMENT. | ^ | 

By Prof. Dickson of S. C. ) ^' I 

THE FOLLOWING ESSAYS ON PHYSIOLOGY AND HY-^ f 
GIENE : — Reid's Experimental Investigation into the Fnnctions 

of the Ei°hih Pair of Nerves. 
Ehrenberg's Microscopical Observations on the Brain and Nerves; 

with numerous Engravings. 
On the Combination of Motor and Sensitive Nervous Activity ; by 

Prof. Stromeyer. Hanover. 
Vegetable Physiology. ^ ^"1 i 1 25 

Experiments on the Brain, Spinal Marrow, and Nerves. By Prof. 

Maver, of Bonn ; with wood cuts. 
PabUc Hygiene. 
Progress of the Anatomv and Physiology of the Nervous System, 

daring 1836. By Pro.' Muller. 
Vital Statistics. 
REID on the FUNCTIONS of the EIGHTH PAIR of NERVES. J 1. 



CJ 



FRECKLETON'S OUTLINES of GENERAL PATHOLOGY. 7 sheets. . 



URI>'ARY DISEASES, and their TREATMENT. By R. Willis, M.D., «S:c. 

10 sheets. . ^ . • • • . 1 'X) 

MILUNGENS CURIOSITIES of MEDICAL EXPERIENCE. 15 sheets. 1 5( 



ANDRAL'S MEDICAL CLINIC: Diseases of the Encephalon, Spinal Cord, 

dec. &c. 13 sheets- . • . . 1 GO 



The ECLECTIC JOURNAL of MEDICINE, by John BeU, MD , 6ic., from 

November, 1837, to October, 1838. 21 sheets. . . . $2 00 



in the Select Medical Library, — extra. 



LECTURES on the PHYSIOLOGY and DISEASES of the CHEST. By 
Prof. Williams. With Engravings. 15 sheets. .... 



LECTURES on BLOOD-LETTING. By Dr. Clutterbuck. 5 sheets. . 65 

MEDICAL and TOPOGRAPHICAL OBSERVATIONS upon the MEDI- 
TERRANEAN, and upon PORTUGAL, SPAIN, and other countries. By 
G. R. B. Horner, Surgeon U. S. N., &c. Illustrated with Engravings. 
9 sheets. . . . . . . . 1 00 



MAGENDIE'S LECTURES on the BLOOD : its Changes during Disease, 

&c. 12 sheets. . . . . . . . 1 25 



The ECLECTIC JOURNAL of MEDICINE, by John Bell, M.D., &c., from 
November, 1838, to October, 1839. 20 sheets. . . . 2 00 



HOLLAND'S MEDICAL NOTES and REFLECTIONS. 16 sheets. . 1 60 



ARMY METEOROLOGICAL REGISTER for the YEARS 1826,^ 
1827, 1828, 1829, and 1830. I 

HINTS on the MEDICAL EXAMINATION of RECRUITS for the ! « ; n r^- 

ARMY; and on the Discharge of Soldiers from the Service on ("S j 
Surgeon's Certificate: Adapted to the Service of the United States. By | co 
Thomas Henderson, M.D., Assistant Surgeon U. S. Army, &c., &c.J [_ 

MACARTNEY on INFLAMMATION. 5 sheets. . . .0 50 



BURNE on HABITUAL CONSTIPATION— its Causes and Consequences. 
7 sheets. . . . . . . .0 



A PRACTICAL TREATISE on VENEREAL DISORDERS, &c.^ ^ f 
By P. Ricord of the Venerea\ Hospital, Paris. 1 % \ 

AMUSSAT'S LECTURES on the RETENTION of URINE, )>_g < 75 
CAUSED by STRICTU RES of the URETHRA, and on the Diseases \ ^ \ 
of the Prostate. Translated from the French by James P. Jervey, M.D.J *> l^ 



ESQUIROL on MENTAL DISEASES. 1 ^ f 

AN ESSAY ON HYSTERIA. With numerous Illustrative and Curious }%{ 1 00 
Cases. By Thomas Laycock. 1^1 

CLINICAL REMARKS on some Cases of LIVER ABSCESS pre-^ f 
senting externally. By John G. Malcolmson, M.D., Surgeon Hon. E. I. ! « I 
C. Service, &c. IgJ 945 

THOMSON'S NOTICES of INFLAMMATORY AFFECTIONS [-= ^, 
of the INTERNAL ORGANS after EXTERNAL INJURIES and | ^ | 
SURGICAL OPERATIONS. J I 

The ECLECTIC JOURNAL of MEDICINE, by John Bell, M.D., &c., from 

November, 1839, to October, 1840. 20 sheets. . . . 2 00 

STOKES'S LECTURES on the THEORY and PRACTICE of PHYSIC. 

With mimerous Notes and Twelve Additional Lectures, by John Bell, M.D., 

Lecturer on the Institutes of Medicine and Medical Jurisprudence. 28 sheets. 2 75 

"We feel great confidence, as well as pleasure, in recommending the present edition of Dr. Stokes's 

Lectures as a valuable addition lo the systematic works on the Theory and Practice of Medicine now in 

general use— as well for the instruction of the student, as for the frequent reference of the medical prac 

litioner." — Amer. our. Med. Sciences. Jan. 1841. 

" Dr Bell's aJditions to the labours of Dr. Stokes are hidily valuable. No writer on Practical Medi- 
cine of tlie present day has higher claims to the confidence "of the profession, than the distinguished 
teacher at Dublin ; and Dr. Bell has hma sCood in the first rank of American medical writers, j.esides 
his Lectures, twelve in number, Dr. Bell has added copious notes to the lectures of Dr. Stokes. The 
volume is handsomely printed, on good paper." — Western Journ. of Med. and Surgery. 

GOOCH'S PRACTICAL COMPENDIUM of MIDWIFERY. 14 sheets. . 1 00 



GRAVES'S CLINICAL LECTURES. With Notes and Fifteen additional 
Lectures, by W. W. Gerhard, Lecturer on Clinical Medicine to the University 
of Pennsylvania, etc. 23 sheets. . . . . . . 2 50 

xxiii 



Just Published, 

BT 

ROBSILT J. GRAVES, IM.D., SME.R.S.Am jv 

PKOPESSOK OF THE IKSTITITTES OF MEHICINE TS THE SCHOOL OF PHYSIC, THIKITT 

COLLEGE, DTTBLIIV ; /" 

^/TTfl' JlDBlTIONJiL LECTURES AND NOTES, 

BY 

W. W. GERHARD, M.D., 

XECTimER OX CLIKICAL MEDICINE TO THE UKIYERSITT OF PENIfSTLTAKIA, PHTSICIABT 
TO THE PHILADELPHIA HOSPITAL, BLOCKLET, ETC., ETC., ETC. 



Recently Published, 
COOFER'S SURaSRir. 

BY TYRRELL. 

S B' ® IS H E^S 

LECTURES OSr THE THEORIT AND FRACTICE OF 

FHVSIC. 

With Numerous Notes and Twelve Additional Lectures 

^Y JOHN BELL, M.D., 

Lecturer on Materia Medica and Therapeutics, Fellow of the College of Physicians 

of Philadelphia, Member of the American Philosophical Society, Corresponding 

Secretary of the Medical College of Philadelphia, etc., etc. 

FZiUI^BE ON DISEASES OF THE SKIN. 

With coloured Plates. 

A PRACTICAL DICTIONARY OF 
3MEATERIA in E D I C A: 

Including a large number of extemporaneous FormulcB, 
By JOHN BELL, M.D., 

Lecturer on Materia Medica, Fellow of the College of Physicians of Philadelphia, etc. 
GOOCK'S mXZDVKTIFERir, 

HORNER'S OBSERVATIONS ON THE 3MIEDZTER- 

RANEAN, ETC. 

JOHN HUNTER'S C^BIFIiETE WORKS. 
CURIOSITIES OF IMUESDICAIi EXFERIENCE. 

CUTLER ON BANDAGING. 

With 100 Illustrations. 

iETIOIiOGir AND SEIMCEIOLOGIT: 

CONSISTING OF 

ARETJEUS ON THE CAUSES AND SIGNS OF ACUTE DISEASE 

AND 

SCHILL'S OUTLINES OF PATHOLOGICAL SEMEIOLOGY. 



